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  • Question 1 - A 28-year-old man visits his General Practitioner, requesting a health check. While he...

    Correct

    • A 28-year-old man visits his General Practitioner, requesting a health check. While he feels very well, he is concerned, as his father had a myocardial infarction (MI) at the age of 43.
      On examination, his blood pressure and pulse are normal. His body mass index (BMI) is also within the normal range. There is a white/grey opacity surrounding the periphery of his cornea in both eyes.
      What is the most appropriate investigation for this patient?

      Your Answer: Lipid profile

      Explanation:

      Appropriate Laboratory Tests for Cardiovascular Health Check

      To assess a patient’s cardiovascular health, various laboratory tests may be conducted. However, the choice of tests should be based on the patient’s symptoms, medical history, and physical examination. In the case of a patient with signs of hyperlipidaemia, a lipid profile would be the most appropriate test to diagnose familial hyperlipidaemia. On the other hand, an ECG would be indicated if there was a family history of sudden death to rule out underlying rhythm issues. A fasting glucose test would not be necessary in this case, but it may be conducted as part of a cardiovascular health check. A full blood count would not aid in the diagnosis of hyperlipidaemia, but it may be conducted if the patient was experiencing chest pain to exclude anaemia as a cause of his symptoms. Lastly, a renal profile would not aid in the diagnosis of familial hyperlipidaemia, but it may be conducted to rule out secondary causes if the patient were hypertensive.

    • This question is part of the following fields:

      • Cardiovascular
      9.5
      Seconds
  • Question 2 - A 68-year-old man comes to the clinic complaining of central chest pain that...

    Correct

    • A 68-year-old man comes to the clinic complaining of central chest pain that started 8 hours ago. The pain is spreading to his left jaw. He has a medical history of hypertension and hyperlipidaemia.

      Upon conducting an ECG, it shows ST elevation in leads II, III and aVF. Troponin levels are significantly elevated. The patient is given 300mg of aspirin and sublingual glyceryl trinitrate.

      Unfortunately, the nearest hospital that can provide primary percutaneous coronary intervention (PCI) is 4 hours away. What is the most appropriate course of action?

      Your Answer: Administer fibrinolysis

      Explanation:

      For the management of STEMI, guidelines recommend primary PCI within 120 minutes of presentation or within 12 hours of symptom onset. As this patient presented with 10 hours of pain and transfer to the nearest hospital for PCI would take 3 hours, fibrinolysis should be offered instead. Giving unfractionated heparin and a glycoprotein IIb/IIIa inhibitor is inappropriate in this case. The patient should not be immediately transferred for PCI, but if the ST elevation is not resolved on a repeat ECG taken 90 minutes after fibrinolysis, then transfer for PCI should be considered. Rechecking troponin in 120 minutes is not necessary, and repeating an ECG in 120 minutes is not the next most important step. Administering fibrinolysis and taking a repeat ECG at the 90-minute mark are the appropriate next steps.

      Managing Acute Coronary Syndrome: A Summary of NICE Guidelines

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

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

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

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

    • This question is part of the following fields:

      • Cardiovascular
      33.4
      Seconds
  • Question 3 - A 28-year-old female presents to the hospital with palpitations. On ECG, a shortened...

    Correct

    • A 28-year-old female presents to the hospital with palpitations. On ECG, a shortened PR interval and wide QRS complexes are observed, along with a slurred upstroke in lead II. What is the definitive treatment for this condition?

      Your Answer: Accessory pathway ablation

      Explanation:

      The definitive treatment for this patient’s Wolff-Parkinson White syndrome is ablation of the accessory pathway.

      Understanding Wolff-Parkinson White Syndrome

      Wolff-Parkinson White (WPW) syndrome is a condition that occurs due to a congenital accessory conduction pathway between the atria and ventricles, leading to atrioventricular re-entry tachycardia (AVRT). This condition can cause AF to degenerate rapidly into VF as the accessory pathway does not slow conduction. The ECG features of WPW include a short PR interval and wide QRS complexes with a slurred upstroke, also known as a delta wave. The left or right axis deviation depends on the location of the accessory pathway.

      WPW syndrome is associated with several conditions, including HOCM, mitral valve prolapse, Ebstein’s anomaly, thyrotoxicosis, and secundum ASD. The definitive treatment for WPW syndrome is radiofrequency ablation of the accessory pathway. Medical therapy options include sotalol, amiodarone, and flecainide. However, sotalol should be avoided if there is coexistent atrial fibrillation as it may increase the ventricular rate and potentially deteriorate into ventricular fibrillation.

      In summary, WPW syndrome is a condition caused by a congenital accessory conduction pathway that can lead to rapid degeneration of AF into VF. The ECG features include a short PR interval and a delta wave. WPW syndrome is associated with several conditions, and the definitive treatment is radiofrequency ablation of the accessory pathway. Medical therapy options are available, but sotalol should be avoided in certain cases.

    • This question is part of the following fields:

      • Cardiovascular
      53.8
      Seconds
  • Question 4 - An 80-year-old man visits his primary care physician for a routine check-up. Upon...

    Correct

    • An 80-year-old man visits his primary care physician for a routine check-up. Upon examination, an irregularly irregular heart rate is detected and confirmed to be atrial fibrillation on an ECG. The patient has a medical history of hypertension and type 2 diabetes mellitus. The physician is worried about preventing stroke. What medication would be the most appropriate for this concern?

      Your Answer: Rivaroxaban

      Explanation:

      For reducing the risk of stroke in patients with atrial fibrillation (AF), the first-line anticoagulation should be a direct oral anticoagulant (DOAC) such as rivaroxaban. This recommendation is based on a scenario where a patient is found to have AF during a wellbeing check and requires anticoagulation due to the increased risk of thrombosis. Aspirin is not the correct choice as it is an antiplatelet and not an anticoagulant. While dalteparin and enoxaparin are low molecular weight heparins that are often used for VTE prophylaxis, DOACs are preferred first-line for stroke risk reduction in AF. Patients often prefer DOACs as they are available in tablet form.

      NICE recommends using the CHA2DS2-VASc score to determine the need for anticoagulation in patients with any history of AF. The ORBIT scoring system should be used to assess bleeding risk, but anticoagulation should not be withheld solely on the grounds of age or risk of falls. DOACs are now recommended as the first-line anticoagulant for patients with AF, with warfarin used second-line if a DOAC is contraindicated or not tolerated. Aspirin is not recommended for reducing stroke risk in patients with AF.

    • This question is part of the following fields:

      • Cardiovascular
      73.1
      Seconds
  • Question 5 - A patient with a history of heart failure is experiencing discomfort even at...

    Correct

    • A patient with a history of heart failure is experiencing discomfort even at rest and is unable to engage in any physical activity without symptoms. What is the New York Heart Association classification that best describes the severity of their condition?

      Your Answer: NYHA Class IV

      Explanation:

      NYHA Classification for Chronic Heart Failure

      The NYHA classification is a widely used system for categorizing the severity of chronic heart failure. It is based on the symptoms experienced by the patient during physical activity. NYHA Class I indicates no symptoms and no limitations on physical activity. NYHA Class II indicates mild symptoms and slight limitations on physical activity. NYHA Class III indicates moderate symptoms and marked limitations on physical activity. Finally, NYHA Class IV indicates severe symptoms and an inability to carry out any physical activity without discomfort. This classification system is helpful in determining the appropriate treatment and management plan for patients with chronic heart failure.

    • This question is part of the following fields:

      • Cardiovascular
      9.1
      Seconds
  • Question 6 - A 60-year-old man with no significant medical history presents to the Emergency Department...

    Correct

    • A 60-year-old man with no significant medical history presents to the Emergency Department with an ECG indicative of an anterior myocardial infarction. Tragically, he experiences cardiac arrest shortly after arrival. What is the leading cause of mortality in patients following a heart attack?

      Your Answer: Ventricular fibrillation

      Explanation:

      Complications of Myocardial Infarction

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

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

    • This question is part of the following fields:

      • Cardiovascular
      18.9
      Seconds
  • Question 7 - A 50-year-old man presents to you after experiencing a heart attack 4 weeks...

    Correct

    • A 50-year-old man presents to you after experiencing a heart attack 4 weeks ago. He has been prescribed ramipril, bisoprolol, aspirin, and clopidogrel following the event. Although he was offered a statin, he declined it at the time, feeling that he was being asked to take too many medications simultaneously. He has since read about the advantages of being on a statin and wishes to begin statin therapy. What is the appropriate statin for this patient to start on?

      Your Answer: Atorvastatin 80mg

      Explanation:

      For primary prevention of cardiovascular disease, a dosage of 20mg of atorvastatin is recommended. However, for secondary prevention, a higher dosage of 80 mg is recommended.

      Statins are drugs that inhibit the action of an enzyme called HMG-CoA reductase, which is responsible for producing cholesterol in the liver. However, they can cause some adverse effects such as myopathy, which includes muscle pain, weakness, and damage, and liver impairment. Myopathy is more common in lipophilic statins than in hydrophilic ones. Statins may also increase the risk of intracerebral hemorrhage in patients who have had a stroke before. Therefore, they should be avoided in these patients. Statins should not be taken during pregnancy and should be stopped if the patient is taking macrolides.

      Statins are recommended for people with established cardiovascular disease, those with a 10-year cardiovascular risk of 10% or more, and patients with type 2 diabetes mellitus. Patients with type 1 diabetes mellitus who were diagnosed more than 10 years ago, are over 40 years old, or have established nephropathy should also take statins. It is recommended to take statins at night as this is when cholesterol synthesis takes place. Atorvastatin 20mg is recommended for primary prevention, and the dose should be increased if non-HDL has not reduced for 40% or more. Atorvastatin 80 mg is recommended for secondary prevention. The graphic shows the different types of statins available.

    • This question is part of the following fields:

      • Cardiovascular
      40.2
      Seconds
  • Question 8 - Which of the following types of anti-anginal medication do patients frequently develop tolerance...

    Correct

    • Which of the following types of anti-anginal medication do patients frequently develop tolerance to?

      Your Answer: Standard release isosorbide mononitrate

      Explanation:

      Angina pectoris is a condition that can be managed through various methods, including lifestyle changes, medication, percutaneous coronary intervention, and surgery. In 2011, NICE released guidelines for the management of stable angina. Medication is an important aspect of treatment, and all patients should receive aspirin and a statin unless there are contraindications. Sublingual glyceryl trinitrate can be used to abort angina attacks. The first-line medication should be either a beta-blocker or a calcium channel blocker, depending on the patient’s comorbidities, contraindications, and preferences. If a calcium channel blocker is used as monotherapy, a rate-limiting one such as verapamil or diltiazem should be used. If used in combination with a beta-blocker, a longer-acting dihydropyridine calcium channel blocker should be used. Beta-blockers should not be prescribed concurrently with verapamil due to the risk of complete heart block. If the initial treatment is not effective, medication should be increased to the maximum tolerated dose. If a patient is still symptomatic after monotherapy with a beta-blocker, a calcium channel blocker can be added, and vice versa. If a patient cannot tolerate the addition of a calcium channel blocker or a beta-blocker, other drugs such as long-acting nitrates, ivabradine, nicorandil, or ranolazine can be considered. Nitrate tolerance is a common issue, and patients who take standard-release isosorbide mononitrate should use an asymmetric dosing interval to maintain a daily nitrate-free time of 10-14 hours to minimize the development of nitrate tolerance. This effect is not seen in patients who take once-daily modified-release isosorbide mononitrate. If a patient is taking both a beta-blocker and a calcium-channel blocker, a third drug should only be added while awaiting assessment for PCI or CABG.

    • This question is part of the following fields:

      • Cardiovascular
      8.6
      Seconds
  • Question 9 - You have requested a B-type natriuretic peptide (BNP) test for a patient with...

    Correct

    • You have requested a B-type natriuretic peptide (BNP) test for a patient with suspected heart failure who is in their 60s. The results have shown a slightly elevated BNP level. What could be a possible factor that may cause a falsely elevated BNP result?

      Your Answer: COPD

      Explanation:

      Chronic heart failure is a condition that requires proper diagnosis and management. In 2018, NICE updated their guidelines on the diagnosis and management of this condition. Previously, the first-line investigation was determined by whether the patient had previously had a myocardial infarction or not. However, this is no longer the case. All patients should now have an N-terminal pro-B-type natriuretic peptide (NT‑proBNP) blood test as the first-line investigation.

      Interpreting the NT-proBNP blood 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. B-type natriuretic peptide (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.

      There are different levels of BNP, and each level indicates a different severity of the condition. High levels of BNP are greater than 400 pg/ml (116 pmol/litre) for BNP and greater than 2000 pg/ml (236 pmol/litre) for NTproBNP. Raised levels of BNP are between 100-400 pg/ml (29-116 pmol/litre) for BNP and between 400-2000 pg/ml (47-236 pmol/litre) for NTproBNP. Normal levels of BNP are less than 100 pg/ml (29 pmol/litre) for BNP and less than 400 pg/ml (47 pmol/litre) for NTproBNP.

      It is important to note that several factors can alter the BNP level. Factors that increase BNP levels include left ventricular hypertrophy, ischaemia, tachycardia, right ventricular overload, hypoxaemia (including pulmonary embolism), GFR < 60 ml/min, sepsis, COPD, diabetes, and age > 70. On the other hand, factors that decrease BNP levels include diuretics, ACE inhibitors, beta-blockers, angiotensin 2 receptor blockers, and aldosterone antagonists.

    • This question is part of the following fields:

      • Cardiovascular
      20.5
      Seconds
  • Question 10 - An 80-year-old man visits his GP for a medication review. His blood pressure...

    Correct

    • An 80-year-old man visits his GP for a medication review. His blood pressure is measured at 184/72 and this is verified twice. What would be the most suitable initial treatment?

      Your Answer: Amlodipine

      Explanation:

      According to the 2011 NICE guidelines, the treatment for isolated systolic hypertension should be the same as that for standard hypertension, with calcium channel blockers being the preferred first-line medication for this age group.

      Understanding Isolated Systolic Hypertension

      Isolated systolic hypertension (ISH) is a common condition among the elderly, affecting approximately 50% of individuals over the age of 70. The Systolic Hypertension in the Elderly Program (SHEP) conducted in 1991 found that treating ISH can reduce the risk of strokes and ischaemic heart disease. The first line of treatment for ISH was thiazides. However, the 2011 NICE guidelines recommend treating ISH in the same stepwise manner as standard hypertension, which contradicts the previous approach.

      It is important to understand ISH as it is a prevalent condition among the elderly population. The SHEP study showed that treating ISH can significantly reduce the risk of serious health complications. However, the recommended approach to treating ISH has changed over time, with the 2011 NICE guidelines suggesting a different method than the previous recommendation of using thiazides as the first line of treatment. It is crucial for healthcare professionals to stay up-to-date with the latest guidelines to provide the best possible care for patients with ISH.

    • This question is part of the following fields:

      • Cardiovascular
      21.4
      Seconds
  • Question 11 - A 62-year-old female presents to the Emergency Department complaining of central chest pain...

    Correct

    • A 62-year-old female presents to the Emergency Department complaining of central chest pain that has been radiating to her left arm for the past 30 minutes. Upon examination, an ECG reveals ST elevation in leads II, III, and aVF. Which coronary artery is the most probable culprit?

      Your Answer: Right coronary

      Explanation:

      Anteroseptal changes in V1-V4 indicate involvement of the left anterior descending artery.
      Inferior changes in II, III, and aVF suggest the right coronary artery is affected.
      Anterolateral changes in V1-6, I, and aVL indicate the proximal left anterior descending artery is involved.
      Lateral changes in I, aVL, and possibly V5-6 suggest the left circumflex artery is affected.
      Posterior changes in V1-3 may indicate a posterior infarction, which is confirmed by ST elevation and Q waves in posterior leads (V7-9). This type of infarction is usually caused by the left circumflex artery, but can also be caused by the right coronary artery.
      Reciprocal changes of STEMI are typically seen as horizontal ST depression, tall and broad R waves, upright T waves, and a dominant R wave in V2. It is important to note that a new left bundle branch block (LBBB) may indicate acute coronary syndrome.

      Overall, understanding the correlation between ECG changes and coronary artery territories is crucial in diagnosing acute coronary syndrome. By identifying the specific changes in the ECG, medical professionals can determine which artery is affected and provide appropriate treatment. Additionally, recognizing the reciprocal changes of STEMI and the significance of a new LBBB can aid in making an accurate diagnosis.

    • This question is part of the following fields:

      • Cardiovascular
      13.1
      Seconds
  • Question 12 - A 26-year-old woman gives birth vaginally at 38 weeks gestation and chooses to...

    Correct

    • A 26-year-old woman gives birth vaginally at 38 weeks gestation and chooses to have a physiological third stage of labor. She experiences a blood loss of 800 ml shortly after delivery. The medical team follows an ABCDE approach and starts a warmed crystalloid infusion. There is no history of medical issues or delivery-related trauma.

      What should be the next course of action in managing her condition?

      Your Answer: Compress the uterus and catheterise her

      Explanation:

      To manage a postpartum haemorrhage, an ABCDE approach should be taken, with initial steps including compressing the uterus and catheterising the patient. This is known as ‘mechanical management’ and is appropriate for a primary postpartum haemorrhage (PPH) where uterine atony is the most common cause. IV warmed crystalloid should also be given. Medical management options such as IV oxytocin or IM/IV carboprost should only be considered if mechanical methods fail. It is important to note that IV carboprost should not be administered as it can lead to serious side effects.

      Understanding Postpartum Haemorrhage

      Postpartum haemorrhage (PPH) is a condition where a woman experiences blood loss of more than 500 ml after giving birth vaginally. It can be classified as primary or secondary. Primary PPH occurs within 24 hours after delivery and is caused by the 4 Ts: tone, trauma, tissue, and thrombin. The most common cause is uterine atony. Risk factors for primary PPH include previous PPH, prolonged labour, pre-eclampsia, increased maternal age, emergency Caesarean section, and placenta praevia.

      In managing PPH, it is important to involve senior staff immediately and follow the ABC approach. This includes two peripheral cannulae, lying the woman flat, blood tests, and commencing a warmed crystalloid infusion. Mechanical interventions such as rubbing up the fundus and catheterisation are also done. Medical interventions include IV oxytocin, ergometrine, carboprost, and misoprostol. Surgical options such as intrauterine balloon tamponade, B-Lynch suture, ligation of uterine arteries, and hysterectomy may be considered if medical options fail to control the bleeding.

      Secondary PPH occurs between 24 hours to 6 weeks after delivery and is typically due to retained placental tissue or endometritis. It is important to understand the causes and risk factors of PPH to prevent and manage this life-threatening emergency effectively.

    • This question is part of the following fields:

      • Cardiovascular
      15
      Seconds
  • Question 13 - You assess a 65-year-old man who has recently been discharged from hospital in...

    Correct

    • You assess a 65-year-old man who has recently been discharged from hospital in France following a heart attack. He presents with an echocardiogram report indicating his left ventricular ejection fraction is 38%. Upon examination, his pulse is regular at 76 beats per minute, blood pressure is 126/74 mmHg, and his chest is clear. He is currently taking aspirin, simvastatin, and lisinopril. What is the most appropriate course of action regarding his medication?

      Your Answer: Add bisoprolol

      Explanation:

      The use of carvedilol and bisoprolol has been proven to decrease mortality in stable heart failure patients, while there is no evidence to support the use of other beta-blockers. NICE guidelines suggest that all individuals with heart failure should be prescribed both an ACE-inhibitor and a beta-blocker.

      Drug Management for Chronic Heart Failure: NICE Guidelines

      Chronic heart failure is a serious condition that requires proper management to improve patient outcomes. In 2018, the National Institute for Health and Care Excellence (NICE) updated their guidelines on drug management for chronic heart failure. The guidelines recommend first-line therapy with both an ACE-inhibitor and a beta-blocker, with clinical judgement used to determine which one to start first. Second-line therapy involves the use of aldosterone antagonists, which should be monitored for hyperkalaemia. SGLT-2 inhibitors are also increasingly being used to manage heart failure with a reduced ejection fraction. Third-line therapy should be initiated by a specialist and may include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin, or cardiac resynchronisation therapy. Other treatments such as annual influenza and one-off pneumococcal vaccines are also recommended.

      Overall, the NICE guidelines provide a comprehensive approach to drug management for chronic heart failure. It is important to note that loop diuretics have not been shown to reduce mortality in the long-term, and that ACE-inhibitors and beta-blockers have no effect on mortality in heart failure with preserved ejection fraction. Healthcare professionals should carefully consider the patient’s individual needs and circumstances when determining the appropriate drug therapy for chronic heart failure.

    • This question is part of the following fields:

      • Cardiovascular
      26.8
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  • Question 14 - A 45-year-old man who was previously healthy comes to the clinic complaining of...

    Correct

    • A 45-year-old man who was previously healthy comes to the clinic complaining of increasing shortness of breath over the past four to five months. His father passed away a few years ago due to a lung disease. During the examination, the doctor notices an elevated jugular venous pressure and a palpable heave at the left sternal edge.

      What is the most probable provisional diagnosis?

      Your Answer: Familial primary pulmonary hypertension

      Explanation:

      Differential Diagnosis for Familial Primary Pulmonary Hypertension

      Familial primary pulmonary hypertension is a rare condition that presents with breathlessness, fatigue, angina, or syncope. It has an autosomal dominant pattern of inheritance with incomplete penetrance and physical signs such as elevated JVP, left parasternal heave, pansystolic murmur, right ventricular S4, and peripheral edema. Without treatment, average survival is less than three years. While tricuspid regurgitation may be present, it is best explained in the context of a diagnosis of familial primary pulmonary hypertension. Chronic pulmonary thromboembolism is a more common differential diagnosis that should be considered. Constrictive pericarditis and pulmonary venous hypertension are unlikely diagnoses as they do not run in families. Clinical management requires a specialist with considerable expertise in the field.

    • This question is part of the following fields:

      • Cardiovascular
      34.6
      Seconds
  • Question 15 - A 67-year-old man with a history of hypertension comes in for his yearly...

    Correct

    • A 67-year-old man with a history of hypertension comes in for his yearly hypertension check-up. He is currently on a daily dose of ramipril 10 mg and amlodipine 10mg, but his blood pressure readings have been consistently high at an average of 160/110 mmHg. What medication would be the best addition to his treatment plan?

      Your Answer: Indapamide

      Explanation:

      To improve the poorly controlled hypertension of this patient who is already taking an ACE inhibitor and a calcium channel blocker, the next step is to add a thiazide-like diuretic. Indapamide is the recommended drug for this purpose, although chlortalidone is also an option. Beta-blockers like bisoprolol and alpha-blockers like doxazosin are not appropriate at this stage of treatment. Combining an angiotensin II receptor blocker with ramipril is not advisable due to the risk of electrolyte imbalance and kidney problems. If the patient has confirmed resistant hypertension, a fourth antihypertensive medication may be added or specialist advice sought. For those with low potassium levels, spironolactone may be considered.

      NICE Guidelines for Managing Hypertension

      Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of a calcium channel blocker or thiazide-like diuretic in addition to an ACE inhibitor or angiotensin receptor blocker.

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

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

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

    • This question is part of the following fields:

      • Cardiovascular
      28
      Seconds
  • Question 16 - You are urgently called to the ward where you encounter a 54-year-old woman...

    Incorrect

    • You are urgently called to the ward where you encounter a 54-year-old woman in ventricular tachycardia. The patient had a syncopal episode while walking to the restroom with nursing staff and currently has a blood pressure (BP) of 85/56 mmHg. Although she is oriented to time, place, and person, she is experiencing dizziness. What is the most suitable approach to managing this patient's ventricular tachycardia?

      Your Answer: Metoprolol 5 mg IV

      Correct Answer: Synchronised direct current (DC) cardioversion

      Explanation:

      Treatment Options for Ventricular Tachycardia

      Ventricular tachycardia is a serious cardiac arrhythmia that requires prompt treatment. The Resuscitation Council tachycardia guideline recommends immediate synchronised electrical cardioversion for unstable patients with ventricular tachycardia who exhibit adverse features such as shock, myocardial ischaemia, syncope, or heart failure. Synchronised cardioversion is preferred over unsynchronised cardioversion as it reduces the risk of causing ventricular fibrillation or cardiac arrest.

      In the event that synchronised cardioversion fails to restore sinus rhythm after three attempts, a loading dose of amiodarone 300 mg IV should be given over 10-20 minutes, followed by another attempt of cardioversion. However, in an uncompromised patient with tachycardia and no adverse features, the first-line treatment involves amiodarone 300 mg as a loading dose IV, followed by an infusion of 900 mg over 24 hours.

      It is important to note that digoxin and metoprolol are not appropriate treatments for ventricular tachycardia. Digoxin is used in the treatment of atrial fibrillation, while metoprolol is a β blocker that should be avoided in patients with significant hypotension, as it can further compromise the patient’s condition.

    • This question is part of the following fields:

      • Cardiovascular
      47.3
      Seconds
  • Question 17 - A 55-year-old woman had a recent acute myocardial infarction (MI).
    Which medication has been...

    Correct

    • A 55-year-old woman had a recent acute myocardial infarction (MI).
      Which medication has been proven to reduce mortality after an MI?

      Your Answer: Bisoprolol

      Explanation:

      Medications for Post-Myocardial Infarction Patients

      Post-myocardial infarction (MI) patients require specific medications to prevent further cardiovascular disease and improve their overall health. One of the most important drugs to offer is a beta-blocker, such as bisoprolol, as soon as the patient is stable. This medication should be continued for at least 12 months after an MI in patients without left ventricular systolic dysfunction or heart failure, and indefinitely in those with left ventricular systolic dysfunction. While beta-blockers can reduce mortality and morbidity for up to a year after an MI, recent studies suggest that continuing treatment beyond a year may not provide any additional benefits. Other medications, such as amiodarone, isosorbide mononitrate, and nicorandil, offer symptom relief but do not reduce mortality or morbidity. Calcium-channel blockers, like diltiazem, may be considered for secondary prevention in patients without pulmonary congestion or left ventricular systolic dysfunction if beta-blockers are contraindicated or discontinued. However, current guidelines recommend offering all post-MI patients an ACE inhibitor, dual antiplatelet therapy, beta-blocker, and statin to improve their long-term health outcomes.

    • This question is part of the following fields:

      • Cardiovascular
      13.9
      Seconds
  • Question 18 - A 65-year-old man is referred by his general practitioner for advice regarding optimisation...

    Correct

    • A 65-year-old man is referred by his general practitioner for advice regarding optimisation of secondary prevention. He has a history of non-ST-elevation myocardial infarction (NSTEMI) two years ago. He is on a combination of clopidogrel, atenolol 50 mg once daily and atorvastatin 80 mg once daily. He also has diabetes for which he takes metformin 1 g twice daily. His pulse rate is 70 bpm, and blood pressure 144/86 mmHg. His past medical history includes an ischaemic stroke two years ago, from which he made a complete recovery.
      What additional therapy would you consider?
      Select the SINGLE most appropriate option from the list below. Select ONE option only.

      Your Answer: Perindopril

      Explanation:

      The Importance of ACE Inhibitors in Post-MI Patients with Vascular Disease and Diabetes

      Following a myocardial infarction (MI), the National Institute for Health and Care Excellence (NICE) recommends the use of angiotensin-converting enzyme (ACE) inhibitors for all patients, regardless of left ventricular function. This is based on evidence from trials such as PROGRESS and HOPE, which demonstrate the benefits of ACE inhibitors in patients with vascular disease. Additionally, for patients with diabetes, the use of ACE inhibitors is preferable. The benefits of ACE inhibition are not solely related to blood pressure reduction, but also include favorable local vascular and myocardial effects. Calcium channel blockers, such as amlodipine and diltiazem, are not recommended for post-MI patients with systolic dysfunction. Nicorandil should also be avoided. Clopidogrel is the preferred antiplatelet for patients with clinical vascular disease who have had an MI and a stroke. Blood pressure should be optimized in post-MI patients, and further antihypertensive therapy may be necessary, including the addition of an ACE inhibitor to achieve the desired level.

    • This question is part of the following fields:

      • Cardiovascular
      46.2
      Seconds
  • Question 19 - A 65-year-old woman was diagnosed with angina after presenting to the Emergency Department...

    Incorrect

    • A 65-year-old woman was diagnosed with angina after presenting to the Emergency Department with exertional chest pain. She had a positive exercise test at the Cardiology Clinic and was started on aspirin, metoprolol, rosuvastatin and a glyceryl trinitrate (GTN) spray.
      Eight months later, she presented to her General Practitioner with an increasing frequency of anginal episodes. These responded to GTN spray and did not occur at rest.
      Which of the following is the most appropriate additional medication?

      Your Answer: Diltiazem

      Correct Answer: Amlodipine

      Explanation:

      The treatment of stable angina involves lifestyle changes, medication, percutaneous coronary intervention, and surgery. The first-line treatment recommended by NICE is either a beta-blocker or a calcium-channel blocker (CCB), depending on the patient’s comorbidities, contraindications, and preferences. If a beta-blocker at the maximum tolerated dose is not controlling angina, a long-acting dihydropyridine CCB, such as amlodipine, modified-release nifedipine, or modified-release felodipine, should be added. Aspirin and a statin should also be given, along with sublingual GTN to abort angina attacks.

      However, if a patient is taking a beta-blocker, a non-rate-limiting long-acting dihydropyridine CCB should be used instead of diltiazem, as the combination of diltiazem and a beta-blocker can lead to life-threatening bradycardia and heart failure. If a patient cannot tolerate a beta-blocker or CCB, ivabradine, nicorandil, or ranolazine can be considered. Ivabradine should only be used on specialist advice and cannot be initiated if the resting heart rate is less than 70 bpm. Nicorandil induces vasodilation of arterioles and large coronary arteries by activating potassium channels. Verapamil should also be avoided in combination with a beta-blocker, as it can result in life-threatening bradycardia and heart failure.

    • This question is part of the following fields:

      • Cardiovascular
      45.3
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  • Question 20 - A 70-year-old patient was discovered to have an abdominal aortic aneurysm during a...

    Correct

    • A 70-year-old patient was discovered to have an abdominal aortic aneurysm during a routine medical check-up. The patient is currently receiving treatment for hypertension and high cholesterol but is otherwise healthy and medically capable. The aneurysm was infra-renal and had a diameter of 4.9 cm.
      What is the best course of action for managing this patient?

      Your Answer: Ultrasound scan every three months

      Explanation:

      Screening and Management of Abdominal Aortic Aneurysms

      Abdominal aortic aneurysms (AAAs) are screened for initially by an ultrasound scan of the abdomen. Men are invited for an initial ultrasound during the year of their 65th birthday, while women are not routinely screened as AAA is predominantly found in men.

      If the initial scan shows an AAA of less than 3 cm, patients are discharged. If it is between 3 and 4.4 cm, they are invited back for yearly screening. If it is between 4.5 and 5.4 cm, patients receive an ultrasound scan every three months. If the aneurysm is above 5.5 cm, patients are referred to a vascular surgeon for consideration for repair.

      Elective surgery is recommended for aneurysms larger than 5.5 cm in diameter or those that are growing rapidly, as clinical trials have shown that the risk of rupture is increased when the aneurysm is larger than 5.5 cm. Immediate surgery is only performed on those aneurysms that are leaking or ruptured.

      Surveillance is required to ensure the aneurysm remains below 5.5 cm. Patients with an aneurysm over 4.5 cm require an ultrasound scan every three months. Once the aneurysm reaches 5.5 cm, patients are referred for consideration of elective surgery.

      Managing Abdominal Aortic Aneurysms: Screening and Treatment Guidelines

      Abdominal aortic aneurysms (AAAs) are a serious health concern that require careful management. This article outlines the screening and treatment guidelines for AAAs.

      Screening for AAAs is done initially by an ultrasound scan of the abdomen. Men are invited for an initial ultrasound during the year of their 65th birthday, while women are not routinely screened. Patients with an AAA less than 3 cm are discharged, while those with an AAA between 3 and 4.4 cm are invited back for yearly screening. Patients with an AAA between 4.5 and 5.4 cm require an ultrasound scan every three months, while those with an AAA over 5.5 cm are referred to a vascular surgeon for consideration of elective surgery.

      Elective surgery is recommended for aneurysms larger than 5.5 cm in diameter or those that are growing rapidly.

    • This question is part of the following fields:

      • Cardiovascular
      13.3
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  • Question 21 - A 25-year-old woman presents with recurrent syncope following aerobics classes. On examination, a...

    Correct

    • A 25-year-old woman presents with recurrent syncope following aerobics classes. On examination, a systolic murmur is heard that worsens with the Valsalva manoeuvre and improves on squatting. What is the most likely diagnosis?

      Your Answer: Hypertrophic cardiomyopathy (HCM)

      Explanation:

      Differentiating Causes of Syncope: A Guide

      Syncope, or fainting, can be caused by a variety of underlying conditions. One such condition is hypertrophic cardiomyopathy (HCM), which often presents with syncope following exercise. Patients with HCM may also have a mid-systolic murmur and a jerky pulse, which worsens with Valsalva but improves with squatting.

      Atrial fibrillation, on the other hand, typically presents with palpitations, fatigue, or shortness of breath, but not syncope. It does not cause a murmur and results in an irregularly irregular pulse.

      Epilepsy is not a common cause of syncope, as typical seizures involve loss of consciousness, tensing, shaking, and postictal fatigue.

      Aortic stenosis can cause dizziness and syncope, and is usually associated with angina. The murmur associated with aortic stenosis is a crescendo-decrescendo murmur that radiates to the carotids.

      A vasovagal attack, while it can cause syncope, would not cause a murmur. If syncope is recurrent, other causes should be sought.

      Dyspnea is a common complaint in patients with HCM, but they may also experience angina or syncope. A left ventricular apical impulse, a prominent S4 gallop, and a harsh systolic ejection murmur are typical findings. The Valsalva maneuver can increase the murmur. An echocardiogram is the diagnostic procedure of choice.

      Most patients with aortic stenosis have gradually increasing obstruction for years but do not become symptomatic until their sixth to eighth decades.

    • This question is part of the following fields:

      • Cardiovascular
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  • Question 22 - A 63-year-old woman with no significant medical history presents with chest pain and...

    Incorrect

    • A 63-year-old woman with no significant medical history presents with chest pain and an ECG showing anterolateral T wave inversion. Her troponin I level at 12 hours is 300 ng/L (reference range < 50 ng/L). She is managed conservatively and discharged on aspirin, atorvastatin, bisoprolol, and ramipril. What is the appropriate use of ticagrelor in this case?

      Your Answer: Should be prescribed for life for all patients

      Correct Answer: Should be prescribed for the next 12 months for all patients

      Explanation:

      Myocardial infarction (MI) is a serious condition that requires proper management to prevent further complications. In 2013, NICE released guidelines on the secondary prevention of MI. One of the key recommendations is the use of four drugs: dual antiplatelet therapy (aspirin plus a second antiplatelet agent), ACE inhibitor, beta-blocker, and statin. Patients are also advised to adopt a Mediterranean-style diet and engage in regular exercise. Sexual activity may resume four weeks after an uncomplicated MI, and PDE5 inhibitors may be used six months after the event.

      Most patients with acute coronary syndrome are now given dual antiplatelet therapy, with ticagrelor and prasugrel being the preferred options. The treatment period for these drugs is 12 months, after which they should be stopped. However, this period may be adjusted for patients at high risk of bleeding or further ischaemic events. Additionally, patients with heart failure and left ventricular systolic dysfunction should be treated with an aldosterone antagonist within 3-14 days of the MI, preferably after ACE inhibitor therapy.

      Overall, the NICE guidelines provide a comprehensive approach to the secondary prevention of MI. By following these recommendations, patients can reduce their risk of further complications and improve their overall health outcomes.

    • This question is part of the following fields:

      • Cardiovascular
      50.7
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  • Question 23 - A 42 year old athlete visits his team physician for a yearly check-up....

    Incorrect

    • A 42 year old athlete visits his team physician for a yearly check-up. What ECG findings should be considered worrisome?

      Your Answer: Wenckebach phenomenon

      Correct Answer: Left bundle branch block

      Explanation:

      Left bundle branch block is typically indicative of underlying ischaemic or structural heart disease and is never considered normal. However, there are several normal variants that can appear on an ECG, such as sinus arrhythmia, right axis deviation (common in tall and thin individuals), left axis deviation (common in short, obese individuals), and partial right bundle branch block. Additionally, athletes may exhibit certain normal variants due to their high vagal tone, such as sinus bradycardia and 1st degree atrioventricular block.

      Normal Variants in Athlete ECGs

      Athletes may exhibit certain ECG changes that are considered normal variants. These include sinus bradycardia, junctional rhythm, first degree heart block, and Mobitz type 1 (Wenckebach phenomenon). Sinus bradycardia refers to a slower than normal heart rate originating from the sinus node, which is the natural pacemaker of the heart. Junctional rhythm occurs when the heart’s electrical impulses originate from the junction between the atria and ventricles, rather than the sinus node. First degree heart block is a delay in the electrical conduction between the atria and ventricles, resulting in a prolonged PR interval on the ECG. Mobitz type 1, also known as Wenckebach phenomenon, is a type of heart block where there is a progressive lengthening of the PR interval until a beat is dropped. These ECG changes are considered normal in athletes and do not necessarily indicate any underlying cardiac pathology.

    • This question is part of the following fields:

      • Cardiovascular
      11.7
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  • Question 24 - A 65-year-old woman has a significant anterior non-ST-elevation myocardial infarction (MI) but recovers...

    Correct

    • A 65-year-old woman has a significant anterior non-ST-elevation myocardial infarction (MI) but recovers well in hospital. Her predischarge echocardiogram shows her to have an ejection fraction of 40%. She is otherwise asymptomatic.
      Which of the following should her medications on discharge include?

      Your Answer: Aspirin, ticagrelor, bisoprolol, ramipril and a statin

      Explanation:

      Medication Options for Post-Myocardial Infarction Patients

      After a myocardial infarction (MI), it is important for patients to receive appropriate medication to prevent further cardiovascular events. The National Institute for Health and Care Excellence (NICE) guidelines recommend the use of aspirin, ticagrelor, bisoprolol, ramipril, and a statin for dual antiplatelet therapy, β-blocker, ACE inhibitor, and cholesterol-lowering medication. The β-blocker and ACE inhibitor should be increased to the maximum tolerated dose.

      While isosorbide mononitrate (ISMN) is a useful anti-anginal medication, it is not indicated for post-MI patients. Instead, aspirin, bisoprolol, ramipril, losartan, and a statin may be prescribed. However, the use of an ACE inhibitor alongside an angiotensin receptor blocker (ARB) is not recommended due to their similar mechanism of action. Nitrates, such as ISMN, are also used as anti-anginals, but ACE inhibitors are preferred over ARBs.

      For patients on aspirin, bisoprolol, ramipril, and a statin, a second antiplatelet medication, such as clopidogrel, may be added for the first 12 months following an MI, unless there is a contraindication such as concomitant use of warfarin. It is important for healthcare providers to carefully consider the appropriate medication regimen for each post-MI patient to optimize their cardiovascular health.

    • This question is part of the following fields:

      • Cardiovascular
      40.3
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  • Question 25 - A 72-year-old man with a history of atrial fibrillation and essential hypertension visits...

    Correct

    • A 72-year-old man with a history of atrial fibrillation and essential hypertension visits his GP for a routine blood pressure check. His blood pressure reading is 152/92 and he wants to know if there are any other ways to reduce his risk of stroke. He is not currently taking any medication.
      What is the most suitable treatment advice to give him?

      Your Answer: Warfarin / NOAC

      Explanation:

      Treatment options for stroke prevention in atrial fibrillation patients: Understanding CHADS-VASc score

      Atrial fibrillation (AF) patients with a CHADS-VASc score of 3 or higher require treatment with either warfarin or a novel oral anticoagulant (NOAC) to prevent stroke. Aspirin, clopidogrel, low-molecular-weight heparin, and strict dietary modification are not recommended for stroke prevention in AF patients.

      The CHADS-VASc score is used to calculate the risk of stroke in AF patients. The score includes factors such as congestive cardiac failure, hypertension, age, diabetes mellitus, previous stroke or transient ischaemic attack, vascular disease, and sex category. Men with a score of 2 or higher are considered to be at high risk of stroke and should start treatment with warfarin or a NOAC. Men with a score of 1 are considered to be at moderate risk and should consider anticoagulation. Women aged <65 years with no other risk factors are considered to be at low risk and do not require anticoagulation. Clopidogrel is an oral antiplatelet agent used in the prevention of atherosclerotic events in patients with coronary artery disease, peripheral arterial disease, and cerebrovascular disease. It is not recommended for stroke prevention in AF patients. Strict dietary modification is not an appropriate treatment for AF and essential hypertension. Low molecular weight heparins (LMWHs) are not used in the management of AF. They are commonly used in the prevention and treatment of venous thromboembolism, unstable angina, and acute myocardial infarction.

    • This question is part of the following fields:

      • Cardiovascular
      48.2
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  • Question 26 - A 63-year-old man with angina and breathlessness at rest is found to have...

    Correct

    • A 63-year-old man with angina and breathlessness at rest is found to have severe aortic stenosis. Since he has no prior medical history, he undergoes an open aortic valve replacement and a mechanical valve is implanted. What is the most suitable medication for long-term anticoagulation after the surgery?

      Your Answer: Warfarin

      Explanation:

      Prosthetic Heart Valves: Options for Replacement

      Prosthetic heart valves are commonly used to replace damaged aortic and mitral valves. There are two main options for replacement: biological (bioprosthetic) or mechanical. Biological valves are usually sourced from bovine or porcine origins and are commonly used in older patients. However, they have a major disadvantage of structural deterioration and calcification over time. On the other hand, mechanical valves have a low failure rate but require long-term anticoagulation due to the increased risk of thrombosis. Warfarin is still the preferred anticoagulant for patients with mechanical heart valves, and the target INR varies depending on the valve type. Aspirin is only given in addition if there is an additional indication, such as ischaemic heart disease. Following the 2008 NICE guidelines, antibiotics are no longer recommended for common procedures such as dental work for prophylaxis of endocarditis.

    • This question is part of the following fields:

      • Cardiovascular
      35
      Seconds
  • Question 27 - A 59-year-old woman comes in for a routine check-up with her primary care...

    Correct

    • A 59-year-old woman comes in for a routine check-up with her primary care physician. She has a history of type 2 diabetes mellitus and is currently taking metformin and sitagliptin. During her last visit, her blood pressure was measured at 161/88 mmHg and she was advised to undergo 7 days of ambulatory blood pressure monitoring.

      During this visit, her average ambulatory blood pressure is recorded as 158/74 mmHg. All other observations are stable and her cardiorespiratory examination is unremarkable. Her blood sugar level is 6.2 mmol/L.

      What medication would be recommended to manage this patient's blood pressure?

      Your Answer: Lisinopril

      Explanation:

      Regardless of age, ACE inhibitors/A2RBs are the first-line treatment for hypertension in diabetics.

      Blood Pressure Management in Diabetes Mellitus

      Patients with diabetes mellitus have traditionally been managed with lower blood pressure targets to reduce their overall cardiovascular risk. However, a 2013 Cochrane review found that there was little difference in outcomes between patients who had tight blood pressure control (targets < 130/85 mmHg) and those with more relaxed control (< 140-160/90-100 mmHg), except for a slightly reduced rate of stroke in the former group. As a result, NICE recommends a blood pressure target of < 140/90 mmHg for type 2 diabetics, the same as for patients without diabetes. For patients with type 1 diabetes, NICE recommends a blood pressure target of 135/85 mmHg unless they have albuminuria or two or more features of metabolic syndrome, in which case the target should be 130/80 mmHg. ACE inhibitors or angiotensin-II receptor antagonists (A2RBs) are the first-line antihypertensive regardless of age, as they have a renoprotective effect in diabetes. A2RBs are preferred for black African or African-Caribbean diabetic patients. Further management then follows that of non-diabetic patients. It is important to note that autonomic neuropathy may result in more postural symptoms in patients taking antihypertensive therapy. Therefore, the routine use of beta-blockers in uncomplicated hypertension should be avoided, particularly when given in combination with thiazides, as they may cause insulin resistance, impair insulin secretion, and alter the autonomic response to hypoglycemia.

    • This question is part of the following fields:

      • Cardiovascular
      36
      Seconds
  • Question 28 - A 55-year-old woman comes to the clinic after being released from the acute...

    Incorrect

    • A 55-year-old woman comes to the clinic after being released from the acute medical unit 14 days ago. She was admitted due to pleuritic chest pain and shortness of breath, and was diagnosed with a pulmonary embolism. Apixaban was started during her hospital stay. The patient has a clean medical history and is generally healthy. What is the appropriate duration of anticoagulation therapy for this individual?

      Your Answer: 3 months

      Correct Answer: 6 months

      Explanation:

      Patients with ‘unprovoked’ pulmonary embolisms usually require anticoagulation treatment for a duration of 6 months, as there are no temporary risk factors for venous thromboembolism.

      Management of Pulmonary Embolism: NICE Guidelines

      Pulmonary embolism (PE) is a serious condition that requires prompt management. The National Institute for Health and Care Excellence (NICE) updated their guidelines on the management of venous thromboembolism (VTE) in 2020, with some key changes. One of the significant changes is the recommendation to use direct oral anticoagulants (DOACs) as the first-line treatment for most people with VTE, including those with active cancer. Another change is the increasing use of outpatient treatment for low-risk PE patients, determined by a validated risk stratification tool.

      Anticoagulant therapy is the cornerstone of VTE management, and the guidelines recommend using apixaban or rivaroxaban as the first-line treatment following the diagnosis of a PE. If neither of these is suitable, LMWH followed by dabigatran or edoxaban or LMWH followed by a vitamin K antagonist (VKA) can be used. For patients with active cancer, DOACs are now recommended instead of LMWH. The length of anticoagulation is determined by whether the VTE was provoked or unprovoked, with treatment typically stopped after 3-6 months for provoked VTE and continued for up to 6 months for unprovoked VTE.

      In cases of haemodynamic instability, thrombolysis is recommended as the first-line treatment for massive PE with circulatory failure. Patients who have repeat pulmonary embolisms, despite adequate anticoagulation, may be considered for inferior vena cava (IVC) filters. However, the evidence base for IVC filter use is weak.

      Overall, the updated NICE guidelines provide clear recommendations for the management of PE, including the use of DOACs as first-line treatment and outpatient management for low-risk patients. The guidelines also emphasize the importance of individualized treatment based on risk stratification and balancing the risks of VTE recurrence and bleeding.

    • This question is part of the following fields:

      • Cardiovascular
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  • Question 29 - An 83-year-old man who resides in a nursing home arrives at the Emergency...

    Correct

    • An 83-year-old man who resides in a nursing home arrives at the Emergency Department with symptoms of diarrhoea and vomiting. He has been experiencing 8 watery bowel movements per day for the past 3 days and seems disoriented and dehydrated. The patient has a medical history of atrial fibrillation, type II diabetes, and dementia. His heart rate is elevated at 110/min, and his electrocardiogram displays noticeable U waves. What is the probable reason for his ECG alterations?

      Your Answer: Hypokalaemia

      Explanation:

      The ECG changes observed in this scenario are most likely due to hypokalaemia. The patient’s electrolyte balance has been disrupted by vomiting and loose stools, resulting in a depletion of potassium that should be rectified through intravenous replacement. While hypocalcaemia and hypothermia can also cause U waves, they are less probable in this case. Non-ischaemic ST elevation changes may be caused by hyponatraemia. QT prolongation is a common effect of tricyclic antidepressant toxicity.

      ECG Features of Hypokalaemia

      Hypokalaemia is a condition characterized by low levels of potassium in the blood. This condition can be detected through an electrocardiogram (ECG) which shows specific features. The ECG features of hypokalaemia include U waves, small or absent T waves, prolonged PR interval, ST depression, and long QT. The U waves are particularly noticeable and are accompanied by a borderline PR interval.

      To remember these features, one registered user suggests the following rhyme: In Hypokalaemia, U have no Pot and no T, but a long PR and a long QT. It is important to detect hypokalaemia early as it can lead to serious complications such as cardiac arrhythmias and even cardiac arrest. Therefore, regular monitoring of potassium levels and ECGs is crucial for individuals at risk of hypokalaemia.

    • This question is part of the following fields:

      • Cardiovascular
      12.1
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  • Question 30 - A 70-year-old man comes to the clinic complaining of feeling tired and having...

    Correct

    • A 70-year-old man comes to the clinic complaining of feeling tired and having palpitations for the last few days. Upon examination, his pulse is irregularly irregular and beats at a rate of 123 bpm. His blood pressure is 128/78 mmHg and his chest is clear. An ECG confirms that he has atrial fibrillation. What medication should be prescribed to manage his heart rate?

      Your Answer: Bisoprolol

      Explanation:

      When considering a rate control strategy for atrial fibrillation, factors such as age and symptoms should be taken into account. According to NICE guidelines, beta-blockers or rate limiting calcium channel blockers (excluding amlodipine) are preferable options.

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

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

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

    • This question is part of the following fields:

      • Cardiovascular
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  • Question 31 - You perform a medication review for a 75-year-old woman who comes in for...

    Correct

    • You perform a medication review for a 75-year-old woman who comes in for a regular check-up. She has a medical history of ischaemic heart disease, stage 2 CKD, hypertension, and gout. Despite her conditions, she is able to function well on her own and her blood pressure today is 125/72 mmHg. Which medication would you suggest discontinuing?

      Your Answer: Bendroflumethiazide

      Explanation:

      Assessing medications in elderly patients can be challenging, as they may be taking unnecessary or harmful drugs. The STOPP-START Criteria (Gallagher et al., 2008) provides guidance on medications that should be considered for discontinuation in the elderly. In this case, the patient has gout, which can be aggravated by bendroflumethiazide, an outdated thiazide diuretic that is no longer recommended by NICE. Additionally, her blood pressure is well below the target for her age, which is 150/90 mmHg in clinic. Ramipril is a more suitable antihypertensive medication to continue for now, but it may also be discontinued if her blood pressure remains low. The patient requires aspirin and atorvastatin for her ischemic heart disease, and allopurinol for her gout.

      NICE Guidelines for Managing Hypertension

      Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of a calcium channel blocker or thiazide-like diuretic in addition to an ACE inhibitor or angiotensin receptor blocker.

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

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

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

    • This question is part of the following fields:

      • Cardiovascular
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  • Question 32 - A 28-year-old man undergoes a routine electrocardiogram (ECG) as part of an examination...

    Correct

    • A 28-year-old man undergoes a routine electrocardiogram (ECG) as part of an examination at his local general practice surgery.
      On examination, his pulse is 64 bpm and his blood pressure is 120/80 mmHg. The clinician notes a delta wave on the ECG and refers him to the Cardiology Department.
      What is the most likely cause of this irregularity?

      Your Answer: Wolff-Parkinson-White (WPW) syndrome

      Explanation:

      Wolff-Parkinson-White (WPW) syndrome is a condition where there is an extra electrical pathway in the heart, making the patient more susceptible to developing supraventricular tachycardia (SVT). The presence of delta waves, which are a slurred upstroke in the QRS complex, and a shortened PR interval are characteristic of WPW syndrome. Atrial fibrillation (AF), on the other hand, is an irregularly irregular pulse that is diagnosed by the absence of P waves and irregular QRS complexes on an ECG. Delta waves are not typically seen in AF unless the patient also has WPW syndrome. Sinus arrhythmia, which is an irregular rhythm, does not show delta waves on an ECG. Acute myocardial infarction (MI) is not associated with delta waves, but rather with ST elevation or depression and T wave inversion. Supraventricular tachycardia (SVT) is a regular narrow complex tachycardia that may or may not have delta waves, depending on whether the patient has underlying WPW syndrome.

    • This question is part of the following fields:

      • Cardiovascular
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  • Question 33 - A 65-year-old woman is brought to the emergency department by ambulance due to...

    Correct

    • A 65-year-old woman is brought to the emergency department by ambulance due to worsening shortness of breath and palpitations. Upon examination, bilateral crepitations are heard in her lungs and she has bilateral ankle edema. An ECG shows atrial fibrillation with a fast ventricular response, with a heart rate of 157 bpm. A chest x-ray reveals pulmonary edema. Blood tests show normal levels of Hb, platelets, WBC, Na+, K+, urea, creatinine, CRP, magnesium, troponin, and TSH. What is the most appropriate next step in managing this patient?

      Your Answer: Synchronised DC cardioversion

      Explanation:

      Patients who exhibit tachycardia along with symptoms of shock, syncope, myocardial ischaemia, or heart failure should be administered up to three synchronised DC shocks. Synchronised DC cardioversion is recommended for tachycardia with haemodynamic instability, signs of myocardial ischaemia, heart failure, or syncope. In this case, the patient is displaying signs of heart failure, and the elevated troponin levels are likely due to tachycardia rather than acute myocardial infarction (MI). Adenosine is not suitable for this situation as it is used to manage supraventricular tachycardia (SVT) that is not associated with shock, syncope, myocardial ischaemia, or heart failure. Amiodarone may be considered in atrial fibrillation with a fast ventricular response if synchronised DC cardioversion is ineffective, but it would not be the most appropriate management option at this time. IV metoprolol (or oral bisoprolol) is used in fast atrial fibrillation not associated with shock, syncope, myocardial ischaemia, or heart failure. However, since this patient is exhibiting signs of heart failure, this is not the correct course of action.

      Management of Peri-Arrest Tachycardias

      The Resuscitation Council (UK) guidelines for the management of peri-arrest tachycardias have been simplified in the 2015 update. The previous separate algorithms for broad-complex tachycardia, narrow complex tachycardia, and atrial fibrillation have been replaced by a unified treatment algorithm. After basic ABC assessment, patients are classified as stable or unstable based on the presence of adverse signs such as hypotension, pallor, sweating, confusion, or impaired consciousness. If any of these signs are present, synchronised DC shocks should be given, up to a maximum of three shocks.

      The treatment following this is based on whether the QRS complex is narrow or broad and whether the rhythm is regular or irregular. For broad-complex tachycardia, a loading dose of amiodarone followed by a 24-hour infusion is given if the rhythm is regular. If the rhythm is irregular, expert help should be sought as it could be due to atrial fibrillation with bundle branch block, atrial fibrillation with ventricular pre-excitation, or torsade de pointes.

      For narrow-complex tachycardia, vagal manoeuvres followed by IV adenosine are given if the rhythm is regular. If unsuccessful, atrial flutter is considered, and rate control is achieved with beta-blockers. If the rhythm is irregular, it is likely due to atrial fibrillation, and electrical or chemical cardioversion is considered if the onset is less than 48 hours. Beta-blockers are usually the first-line treatment for rate control unless contraindicated. The full treatment algorithm can be found on the Resuscitation Council website.

    • This question is part of the following fields:

      • Cardiovascular
      38.3
      Seconds
  • Question 34 - A woman with a history of asthma who is 25 weeks pregnant is...

    Correct

    • A woman with a history of asthma who is 25 weeks pregnant is found to have consistent blood pressure readings >170/95 mmHg. She is admitted under Gynaecology.
      Which of the following antihypertensives would you initiate for this patient?

      Your Answer: Nifedipine

      Explanation:

      Safe and Effective Treatment Options for Gestational Hypertension

      Gestational hypertension is a serious condition that requires prompt medical attention. According to NICE guidelines, labetalol is the first-line treatment for gestational hypertension. However, if the patient has asthma, labetalol is contraindicated. In such cases, nifedipine is listed as the second-line treatment, followed by methyldopa if necessary.

      Diltiazem is not usually used in gestational hypertension, and the role of this medication in pregnancy is unclear. Bendroflumethiazide is relatively contraindicated in pregnancy, while ACE inhibitors and ARBs are absolutely contraindicated due to their potential adverse effects on fetal blood pressure and renal function.

      In cases of gestational hypertension, it is crucial to rule out pre-eclampsia. If the patient’s blood pressure is above 160/110, NICE guidelines recommend admission until the blood pressure is below this level.

      Calcium channel blockers, such as nifedipine, are safe and effective in pregnancy, while the role of diltiazem is uncertain. Bendroflumethiazide is relatively contraindicated, while ACE inhibitors and ARBs are absolutely contraindicated. It is essential to choose the appropriate medication based on the patient’s medical history and individual circumstances.

    • This question is part of the following fields:

      • Cardiovascular
      10.9
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  • Question 35 - A 47-year-old man presents to the clinic with concerns about his risk of...

    Correct

    • A 47-year-old man presents to the clinic with concerns about his risk of coronary heart disease after a friend recently had a heart attack. He has a history of anxiety but is not currently taking any medication. He is a 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.

      As his healthcare provider, you strongly advise him to quit smoking. What would be the most appropriate next step?

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

      Explanation:

      The 2014 NICE guidelines recommend using the QRISK2 tool to identify patients over 40 years old who are at high risk of CVD, with a 10-year risk of 10% or greater. A full lipid profile should be checked before starting a statin, and atorvastatin 20mg should be offered first-line. Lifestyle modifications include a cardioprotective diet, physical activity, weight management, limiting alcohol intake, and smoking cessation. Follow-up should occur at 3 months, with consideration of increasing the dose of atorvastatin up to 80 mg if necessary.

    • This question is part of the following fields:

      • Cardiovascular
      43.2
      Seconds
  • Question 36 - A 54-year-old Caucasian man with a history of hypertension visits his GP clinic...

    Correct

    • A 54-year-old Caucasian man with a history of hypertension visits his GP clinic seeking advice on controlling his blood pressure. He has been monitoring his blood pressure at home for the past week and has consistently recorded high readings, with an average of 147/85 mmHg. He is asymptomatic and denies any chest discomfort. He is a non-smoker and non-alcoholic. His current medications include perindopril 10 mg once daily and indapamide 2.5mg once daily. What is the most appropriate course of action for managing his hypertension?

      Your Answer: Amlodipine

      Explanation:

      To improve poorly controlled hypertension despite taking an ACE inhibitor and a thiazide diuretic, a calcium channel blocker such as amlodipine should be added according to NICE guidelines. Loop diuretics may be considered in cases of resistant hypertension. Aldosterone antagonists and alpha-blockers are only recommended if blood pressure remains uncontrolled despite taking a combination of an ACE inhibitor or angiotensin II receptor blocker, a calcium-channel blocker, and a thiazide-like diuretic. It is important to note that ACE inhibitors should not be used in combination with angiotensin receptor blockers for hypertension management.

      NICE Guidelines for Managing Hypertension

      Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of a calcium channel blocker or thiazide-like diuretic in addition to an ACE inhibitor or angiotensin receptor blocker.

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

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

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

    • This question is part of the following fields:

      • Cardiovascular
      45.5
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  • Question 37 - A 45-year-old man attends for a truck driver medical assessment. His blood pressure...

    Correct

    • A 45-year-old man attends for a truck driver medical assessment. His blood pressure (BP) is noted to be 190/100 mmHg. He is a heavy drinker. He is feeling generally well in himself. You request blood tests:
      Result Normal
      Sodium (mmol/l) 138 135-145
      Potassium (mmol/l) 4.0 3.5-5.0
      Urea (mmol/l) 4.8 1.7-8.3
      Creatinine (µmol/l) 152 59-104
      You decide to perform a work-up to exclude a secondary cause for his hypertension. An ultrasound scan of the renal tract reveals a small atrophic left kidney.
      Which of the following is the most likely diagnosis?

      Your Answer: Renal artery stenosis

      Explanation:

      Possible Causes of Hypertension: Differential Diagnosis

      Hypertension in a young patient may indicate a secondary cause, such as renovascular disease. In this case, a small kidney on ultrasound and elevated creatinine levels suggest renal artery stenosis as a possible cause. Other potential diagnoses, such as Cushing’s syndrome, acromegaly, and phaeochromocytoma, are less likely based on the absence of corresponding symptoms and signs. Polycystic kidney disease, which can also cause hypertension, would typically present with bilateral renal enlargement rather than atrophy. A thorough differential diagnosis is important to identify the underlying cause of hypertension and guide appropriate management.

    • This question is part of the following fields:

      • Cardiovascular
      42.1
      Seconds
  • Question 38 - A 48-year-old man comes to the General Practitioner complaining of feeling dizzy and...

    Correct

    • A 48-year-old man comes to the General Practitioner complaining of feeling dizzy and experiencing shortness of breath during physical activity. He has a bicuspid aortic valve and is waiting for valve replacement surgery.
      Which of the following murmurs would be the most likely to occur in this patient?

      Your Answer: Ejection systolic murmur loudest over the 2nd intercostal space, right sternal edge

      Explanation:

      Differentiating Heart Murmurs Based on Location and Type

      Heart murmurs are abnormal sounds heard during a heartbeat and can indicate various cardiac conditions. The location and type of murmur can help differentiate between different conditions.

      Ejection systolic murmur loudest over the 2nd intercostal space, right sternal edge: This is typical for aortic stenosis, which is more likely to occur in a bicuspid aortic valve. The murmur may radiate to the carotids. Pulmonary stenosis, hypertrophic obstructive cardiomyopathy, and atrial septal defect can also cause this type of murmur, but the location would be different.

      Ejection systolic murmur loudest over the 2nd intercostal space, left sternal edge: This location is typical for pulmonary stenosis, not aortic stenosis. The patient’s history indicates symptomatic aortic stenosis, making this finding inconsistent.

      Early diastolic murmur loudest over the 3rd intercostal space, left sternal edge: This type and location of murmur is typical for aortic regurgitation, not aortic stenosis. The location is Erb’s point, where S1 and S2 should both be heard.

      Mid-diastolic murmur loudest over the apex: This type and location of murmur is typical for mitral stenosis, not aortic stenosis. The apex is the mitral area, located at the 5th intercostal space in the midclavicular line.

      Pansystolic murmur loudest over the apex: This type and location of murmur is typical for mitral regurgitation, not aortic stenosis. The apex is the mitral area, located at the 5th intercostal space in the midclavicular line.

    • This question is part of the following fields:

      • Cardiovascular
      51
      Seconds
  • Question 39 - A 45-year-old man presents to the Emergency Department with a 7-day history of...

    Correct

    • A 45-year-old man presents to the Emergency Department with a 7-day history of fever and night sweats. His parameters include a blood pressure of 110/80 mmHg, oxygen saturation of 99%, heart rate of 115 bpm and a temperature of 38.5°C.
      On examination, a murmur is elicited at the right upper sternal edge. Infective endocarditis is suspected and an echocardiogram is done which shows multiple vegetations on the aortic valve.
      Which of the following is the best next step to confirm the diagnosis?
      Select the SINGLE best management option from the list below.
      Select ONE option only.

      Your Answer: Two positive blood cultures drawn > 12 hours apart

      Explanation:

      Diagnosing Infective Endocarditis: Criteria and Testing

      In order to diagnose infective endocarditis, the modified Duke’s criteria are used. One major criterion can be fulfilled by echocardiography and the other by blood cultures. If a patient has one major criterion and one minor criterion, they need another major criterion or at least two other minor criteria to confirm the diagnosis. Two positive blood cultures drawn more than 12 hours apart fulfill the other major criterion, confirming the diagnosis.

      A chest X-ray is not necessary in this case, as it would not provide enough information to support a diagnosis of infective endocarditis.

      If a patient has one major criterion and one minor criterion, one positive blood culture of an atypical organism would fit a minor criterion for diagnosis, but would not be enough to confirm the diagnosis.

      Two positive blood cultures taken at the same time from different sites would not be appropriate, as they need to be drawn at least 12 hours apart to fulfill the major criterion. Even if this criterion is fulfilled, the patient would still need another major criterion or additional minor criteria to confirm the diagnosis.

    • This question is part of the following fields:

      • Cardiovascular
      24.7
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  • Question 40 - An 80-year-old man presents with leg swelling and nocturnal dyspnea. His BNP levels...

    Incorrect

    • An 80-year-old man presents with leg swelling and nocturnal dyspnea. His BNP levels are elevated and an echocardiogram confirms heart failure with reduced ejection fraction. He has a history of diabetes and is currently on metformin. Besides furosemide, what other medication should be initiated for his heart failure management?

      Your Answer: Propranolol

      Correct Answer: Ramipril

      Explanation:

      When treating heart failure patients, it is recommended to initiate therapy with either an angiotensin-converting enzyme (ACE) inhibitor or a beta-blocker licensed for heart failure treatment, but not both simultaneously. If the patient exhibits signs of fluid overload or has diabetes mellitus, an ACE inhibitor like ramipril is preferred. On the other hand, if the patient has angina, a beta-blocker such as bisoprolol, carvedilol, or nebivolol is preferred.

      Drug Management for Chronic Heart Failure: NICE Guidelines

      Chronic heart failure is a serious condition that requires proper management to improve patient outcomes. In 2018, the National Institute for Health and Care Excellence (NICE) updated their guidelines on drug management for chronic heart failure. The guidelines recommend first-line therapy with both an ACE-inhibitor and a beta-blocker, with clinical judgement used to determine which one to start first. Second-line therapy involves the use of aldosterone antagonists, which should be monitored for hyperkalaemia. SGLT-2 inhibitors are also increasingly being used to manage heart failure with a reduced ejection fraction. Third-line therapy should be initiated by a specialist and may include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin, or cardiac resynchronisation therapy. Other treatments such as annual influenza and one-off pneumococcal vaccines are also recommended.

      Overall, the NICE guidelines provide a comprehensive approach to drug management for chronic heart failure. It is important to note that loop diuretics have not been shown to reduce mortality in the long-term, and that ACE-inhibitors and beta-blockers have no effect on mortality in heart failure with preserved ejection fraction. Healthcare professionals should carefully consider the patient’s individual needs and circumstances when determining the appropriate drug therapy for chronic heart failure.

    • This question is part of the following fields:

      • Cardiovascular
      17.9
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  • Question 41 - A geriatric patient presents with chronic heart failure.
    Which of the following drugs should...

    Correct

    • A geriatric patient presents with chronic heart failure.
      Which of the following drugs should be used as a first-line treatment for heart failure?

      Your Answer: Enalapril

      Explanation:

      Heart Failure Medications: Uses and Recommendations

      Heart failure is a serious condition that requires proper management and treatment. There are several medications available for heart failure, each with its own specific uses and recommendations.

      Enalapril is an ACE inhibitor that works by reducing levels of angiotensin II, a potent vasoconstrictor, resulting in reduced vasoconstriction and a reduction in left ventricular afterload. It is recommended as a first-line treatment for all patients with heart failure due to left ventricular systolic dysfunction.

      Digoxin is recommended for worsening or severe heart failure due to left ventricular systolic dysfunction despite first- and second-line treatment for heart failure.

      Aspirin should be prescribed for patients with heart failure and atherosclerotic arterial disease, including coronary heart disease. It is not useful in monotherapy for the treatment of heart failure.

      Furosemide is a diuretic that is routinely used for the relief of congestive symptoms and fluid retention in patients with heart failure. It should be titrated according to need after the initiation of subsequent heart failure therapies.

      Spironolactone is an aldosterone antagonist that forms the second-line treatment in patients with heart failure. It is important to closely monitor potassium and creatinine levels and the estimated glomerular filtration rate (eGFR). Specialist advice should be sought if the patient develops hyperkalaemia or renal function deteriorates.

      In summary, the appropriate medication for heart failure depends on the individual patient’s condition and needs. It is important to consult with a healthcare professional for proper diagnosis and treatment.

    • This question is part of the following fields:

      • Cardiovascular
      17.1
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  • Question 42 - A 50-year old-man comes to see you saying that his father recently passed...

    Incorrect

    • A 50-year old-man comes to see you saying that his father recently passed away due to an abdominal aortic aneurysm. He inquires if he will be screened for this condition and when should he start screening?

      Your Answer: Abdominal ultrasound at 65 and then every 5 years

      Correct Answer: Single abdominal ultrasound at 65

      Explanation:

      Understanding Abdominal Aortic Aneurysms

      Abdominal aortic aneurysms occur when the elastic proteins within the extracellular matrix fail, causing dilation of all layers of the arterial wall. This degenerative disease is most commonly seen in individuals over the age of 50, with diameters of 3 cm or greater considered aneurysmal. The development of aneurysms is a complex process involving the loss of the intima and elastic fibers from the media, which is associated with increased proteolytic activity and lymphocytic infiltration.

      Smoking and hypertension are major risk factors for the development of aneurysms, while rare causes include syphilis and connective tissue diseases such as Ehlers Danlos type 1 and Marfan’s syndrome. It is important to understand the pathophysiology of abdominal aortic aneurysms in order to identify and manage risk factors, as well as to provide appropriate treatment for those affected. By recognizing the underlying causes and risk factors, healthcare professionals can work to prevent the development of aneurysms and improve outcomes for those affected.

    • This question is part of the following fields:

      • Cardiovascular
      22.7
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  • Question 43 - A 65-year-old woman with a recent diagnosis of heart failure with reduced ejection...

    Correct

    • A 65-year-old woman with a recent diagnosis of heart failure with reduced ejection fraction (on echo) has a blood pressure (BP) of 160/95 mmHg. She is currently on lisinopril (maximum doses).
      Which of the following new agents would you add in?

      Your Answer: Bisoprolol

      Explanation:

      Medications for Heart Failure: Benefits and Guidelines

      Heart failure is a serious condition that requires proper management through medications. Among the drugs commonly used are bisoprolol, bendroflumethiazide, clopidogrel, spironolactone, and diltiazem.

      Bisoprolol and an angiotensin-converting enzyme (ACE) inhibitor are recommended for all heart failure patients as they have been shown to reduce mortality. Bendroflumethiazide and loop diuretics like furosemide can help alleviate symptoms but do not have a mortality benefit. Clopidogrel, on the other hand, is not indicated for heart failure but is used for vascular diseases like NSTEMI and stroke.

      Spironolactone is recommended for patients who remain symptomatic despite treatment with an ACE inhibitor and a b blocker. It is also beneficial for those with left ventricular systolic dysfunction (LVSD) after a myocardial infarction (MI). However, diltiazem should be avoided in heart failure patients.

      According to NICE guidelines, b blockers and ACE inhibitors should be given to all LVSD patients unless contraindicated. Spironolactone can be added if symptoms persist. Proper medication management is crucial in improving outcomes for heart failure patients.

    • This question is part of the following fields:

      • Cardiovascular
      26.3
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  • Question 44 - A 50-year-old man arrives at the emergency department complaining of severe chest pain...

    Correct

    • A 50-year-old man arrives at the emergency department complaining of severe chest pain that radiates to his left arm, accompanied by nausea and sweating. His ECG reveals widespread ST depression with T wave inversion, and his blood tests show a haemoglobin level of 75g/L. What is the appropriate treatment for his anaemia?

      Your Answer: Transfusion of packed red cells

      Explanation:

      For patients with ACS, the recommended transfusion threshold is a haemoglobin level of 80 g/L. In this case, the patient is presenting with symptoms of ACS and his ECG confirms this. However, his haemoglobin level is below the threshold, indicating severe anaemia. Therefore, an immediate transfusion is necessary to alleviate the anaemia. Anaemia can exacerbate ischaemia in ACS, leading to increased strain on the heart and reduced oxygen supply. The guidelines suggest aiming for a haemoglobin concentration of 80-100 g/L after transfusion. Oral or IV iron would not provide immediate relief, and IV Hartmann’s solution is not a suitable treatment for anaemia and would not address the underlying issue. This highlights the importance of prompt and appropriate treatment for patients with ACS. This information is based on the NICE guideline [NG24].

      Guidelines for Red Blood Cell Transfusion

      In 2015, NICE released guidelines for the use of blood products, specifically red blood cells. These guidelines recommend different transfusion thresholds for patients with and without acute coronary syndrome (ACS). For patients without ACS, the transfusion threshold is 70 g/L, while for those with ACS, it is 80 g/L. The target hemoglobin level after transfusion is 70-90 g/L for patients without ACS and 80-100 g/L for those with ACS. It is important to note that these thresholds should not be used for patients with ongoing major hemorrhage or those who require regular blood transfusions for chronic anemia.

      When administering red blood cells, it is crucial to store them at 4°C prior to infusion. In non-urgent scenarios, a unit of RBC is typically transfused over a period of 90-120 minutes. By following these guidelines, healthcare professionals can ensure that red blood cell transfusions are administered safely and effectively.

    • This question is part of the following fields:

      • Cardiovascular
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  • Question 45 - A 62-year-old man is undergoing a drug therapy evaluation following a myocardial infarction...

    Correct

    • A 62-year-old man is undergoing a drug therapy evaluation following a myocardial infarction (MI).
      Which of the following options has not been shown to have a beneficial effect on mortality after an MI?

      Your Answer: Isosorbide mononitrate

      Explanation:

      Medications for Post-Myocardial Infarction (MI) Care

      After a myocardial infarction (MI), certain medications are recommended to reduce mortality and manage symptoms. Nitrates, such as isosorbide mononitrate, offer no mortality benefit but can be used for angina symptoms. β-blockers, like timolol, provide both mortality and anti-anginal benefits and should be continued for at least 12 months post-MI. Statins, specifically atorvastatin 80 mg, are recommended for secondary prevention to reduce mortality. Angiotensin-converting enzyme (ACE) inhibitors, such as ramipril, offer good mortality benefit, but angiotensin receptor blockers (ARBs) can be used if the patient cannot tolerate ACE inhibitors. Aspirin, in combination with another antiplatelet therapy, is recommended for 12 months post-MI. Studies have shown that tirofiban, timolol, and ramipril reduce mortality after an MI, while isosorbide mononitrate showed no benefit. The MIRACL study found that atorvastatin reduced cardiovascular events by 17% when given for 3 months post-MI.

    • This question is part of the following fields:

      • Cardiovascular
      25.3
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  • Question 46 - An 80-year-old patient is being treated for symptomatic bradycardia. Despite receiving multiple boluses...

    Correct

    • An 80-year-old patient is being treated for symptomatic bradycardia. Despite receiving multiple boluses of atropine, the patient's condition remains unchanged with a heart rate of 35 beats per minute, blood pressure of 85/55 mmHg, respiratory rate of 22 breaths per minute, oxygen saturation of 98%, and a temperature of 37.3ºC. The patient is experiencing confusion, sweating, and has cold and clammy extremities. What is the most appropriate course of action for managing this patient?

      Your Answer: External pacing

      Explanation:

      Management of Bradycardia in Peri-Arrest Rhythms

      The 2015 Resuscitation Council (UK) guidelines highlight the importance of identifying adverse signs and potential risk of asystole in the management of bradycardia in peri-arrest rhythms. Adverse signs indicating haemodynamic compromise include shock, syncope, myocardial ischaemia, and heart failure. Atropine (500 mcg IV) is the first line treatment in this situation. If there is an unsatisfactory response, interventions such as atropine (up to a maximum of 3mg), transcutaneous pacing, and isoprenaline/adrenaline infusion titrated to response may be used. Specialist help should be sought for consideration of transvenous pacing if there is no response to the above measures.

      Furthermore, the presence of risk factors for asystole such as complete heart block with broad complex QRS, recent asystole, Mobitz type II AV block, and ventricular pause > 3 seconds should be considered. Even if there is a satisfactory response to atropine, specialist help is indicated to consider the need for transvenous pacing. Effective management of bradycardia in peri-arrest rhythms is crucial in preventing further deterioration and improving patient outcomes.

    • This question is part of the following fields:

      • Cardiovascular
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  • Question 47 - A 65-year-old woman with a history of hypertension and heart failure presents with...

    Correct

    • A 65-year-old woman with a history of hypertension and heart failure presents with atrial fibrillation. She is stable with a ventricular rate of 70. Which of the following drug options would be the most suitable for her?

      Your Answer: Warfarin or direct oral anticoagulant (DOAC)

      Explanation:

      Treatment Options for Atrial Fibrillation: Warfarin, DOACs, Aspirin, Digoxin, Furosemide, and Lidocaine

      Patients with atrial fibrillation and a CHA2DS2-VASC score of 4 require anticoagulation to reduce the risk of a CVA. The two main options are warfarin and DOACs, but the choice depends on other co-morbidities and patient preference. Before starting warfarin, patients should be referred to the Anticoagulation Clinic and screened for contraindications.

      Aspirin has no benefit in atrial fibrillation, and digoxin should only be used for short-term rate control due to evidence of increased mortality with long-term use. Furosemide can help with symptoms and edema in heart failure but does not improve mortality. Lidocaine is only appropriate for ventricular arrhythmias in unstable patients and requires specialist support.

      In summary, the treatment options for atrial fibrillation vary depending on the patient’s individual circumstances and should be carefully considered by healthcare professionals.

    • This question is part of the following fields:

      • Cardiovascular
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  • Question 48 - You have just received a 70-year-old man into the resuscitation room who had...

    Correct

    • You have just received a 70-year-old man into the resuscitation room who had a witnessed collapse after complaining of chest pain. There was no pulse, and cardiopulmonary resuscitation (CPR) was performed at the scene. CPR is ongoing upon patient arrival in the Emergency Department. Pulse check demonstrates no palpable central pulse, and there is no respiratory effort. A 3-lead electrocardiogram (ECG) demonstrates no coordinated electrical activity or recognisable complexes, looking very much like a wandering flat line.
      What is the most appropriate management of this patient?

      Your Answer: 1 mg of adrenaline 1 : 10 000 intravenously (IV), and continue CPR

      Explanation:

      Managing Cardiac Arrest: Correct and Incorrect Approaches

      When dealing with a patient in cardiac arrest, it is crucial to follow the correct management protocol. In the case of a patient in asystole, CPR 30:2 (compressions: ventilations) should be initiated, along with 1 mg of adrenaline 10 ml of 1:10 000 IV every other cycle of CPR. Direct current (DC) shock is not indicated for asystole. Adrenaline 1:1000 IM is not appropriate for cardiac arrest situations, as it is used in anaphylaxis. External pacing is unlikely to be successful in the absence of P-wave asystole. Atropine is indicated in severe bradycardia, not asystole. It is essential to follow the correct approach to manage cardiac arrest effectively.

    • This question is part of the following fields:

      • Cardiovascular
      53.8
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  • Question 49 - A 70-year-old man presents with central chest pain that has been ongoing for...

    Correct

    • A 70-year-old man presents with central chest pain that has been ongoing for 2 hours. The pain is radiating to his left arm. He has a medical history of hypertension and hypercholesterolemia.

      Upon examination, the patient appears uncomfortable and sweaty. His vital signs are as follows:
      - Heart rate: 90 bpm
      - Respiratory rate: 20 breaths/min
      - Peripheral oxygen saturation: 95% on room air
      - Blood pressure: 136/78 mmHg
      - Temperature: 37.0ºC

      An ECG performed by the paramedics shows ST depression in leads II, III, and aVF, as well as T-wave inversion.

      What is the immediate treatment that should be given?

      Your Answer: Aspirin, nitrate, morphine

      Explanation:

      The appropriate combination in this scenario is aspirin, nitrate, and morphine. The addition of oxygen is not necessary and may even be inappropriate. Ramipril and bisoprolol are not recommended for acute treatment but may be used for long-term management of ACS. Therefore, aspirin, nitrate, and oxygen is an incorrect combination, and morphine should also be included due to the patient’s significant pain. Oxygen should not be administered as the patient’s oxygen saturation levels are already adequate.

      Managing Acute Coronary Syndrome: A Summary of NICE Guidelines

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

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

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

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

    • This question is part of the following fields:

      • Cardiovascular
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  • Question 50 - A 59 year old man with a history of aortic stenosis presents to...

    Incorrect

    • A 59 year old man with a history of aortic stenosis presents to his cardiology clinic with complaints of worsening shortness of breath and fainting episodes. His recent ECHO reveals a mean gradient of 45 mmHg and mild aortic regurgitation, while his ECG shows left ventricular hypertrophy, left bundle branch block, and a prolonged PR interval. What factor is most indicative of the need for valve replacement surgery?

      Your Answer: Co-existant aortic regurgitation

      Correct Answer: Presence of symptoms

      Explanation:

      Aortic valve replacement is typically recommended for patients with severe aortic stenosis who are experiencing symptoms such as dyspnea, chest pain, and syncope. Without treatment, these symptoms can lead to a mortality rate of 2-3 years. However, the decision to perform valve replacement on asymptomatic patients is a topic of debate.

      Aortic Stenosis: Symptoms, Causes, and Management

      Aortic stenosis is a condition characterized by the narrowing of the aortic valve, which can lead to various symptoms. These symptoms include chest pain, dyspnea, syncope, and a characteristic ejection systolic murmur that radiates to the carotids. Severe aortic stenosis can also cause a narrow pulse pressure, slow rising pulse, delayed ESM, soft/absent S2, S4, thrill, and left ventricular hypertrophy or failure. The most common causes of aortic stenosis are degenerative calcification in older patients and bicuspid aortic valve in younger patients.

      If a patient is asymptomatic, observation is usually recommended. However, if the patient is symptomatic or has a valvular gradient greater than 40 mmHg with features such as left ventricular systolic dysfunction, valve replacement is necessary. Surgical AVR is the preferred treatment for young, low/medium operative risk patients, while TAVR is used for those with a high operative risk. Balloon valvuloplasty may be used in children without aortic valve calcification and in adults with critical aortic stenosis who are not fit for valve replacement.

      In summary, aortic stenosis is a condition that can cause various symptoms and requires prompt management to prevent complications. The causes of aortic stenosis vary, and treatment options depend on the patient’s age, operative risk, and overall health.

    • This question is part of the following fields:

      • Cardiovascular
      27
      Seconds
  • Question 51 - A 63-year-old man presents to the emergency department with sudden-onset chest pain and...

    Correct

    • A 63-year-old man presents to the emergency department with sudden-onset chest pain and nausea. He is not taking any regular medications. An ECG reveals ST depression and T wave inversion in leads V2-V4, and troponin levels are elevated. The patient receives a STAT 300mg aspirin, and there are no immediate plans for primary PCI. According to the GRACE score, the 6-month mortality risk is 8.0%. The patient is stable. What is the best course of treatment going forward?

      Your Answer: Fondaparinux, prasugrel or ticagrelor, and refer for coronary angiography within 72 hours

      Explanation:

      The current treatment plan of prescribing fondaparinux, clopidogrel, and scheduling a coronary angiography in 3 months is incorrect. Clopidogrel is typically prescribed for patients with a higher risk of bleeding or those taking an oral anticoagulant. Additionally, delaying definitive treatment for a high-risk patient by scheduling a coronary angiography in 3 months could lead to increased mortality. Instead, a more appropriate treatment plan would involve prescribing prasugrel, unfractionated heparin, and a glycoprotein IIB/IIIA inhibitor, and referring the patient for urgent PCI within 2 hours. However, it should be noted that this treatment plan is specific to patients with STEMI and access to PCI facilities.

      Managing Acute Coronary Syndrome: A Summary of NICE Guidelines

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

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

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

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

    • This question is part of the following fields:

      • Cardiovascular
      90.2
      Seconds
  • Question 52 - A 65-year-old man presents to his GP for a hypertension review. His home...

    Incorrect

    • A 65-year-old man presents to his GP for a hypertension review. His home readings indicate an average blood pressure of 162/96 mmHg. He reports feeling generally well, and physical examination is unremarkable. Previous investigations have not revealed an underlying cause for his hypertension. Recent blood tests show normal electrolyte levels and kidney function. He is currently on ramipril, amlodipine, and bendroflumethiazide. What would be the most appropriate medication to add for the management of this patient's hypertension?

      Your Answer: Spironolactone

      Correct Answer: Alpha-blocker or beta-blocker

      Explanation:

      If a patient has poorly controlled hypertension and is already taking an ACE inhibitor, calcium channel blocker, and a standard-dose thiazide diuretic, and their potassium level is above 4.5mmol/l, the best option is to add an alpha- or beta-blocker. According to NICE guidelines, this patient has resistant hypertension, which is stage 4 of the NICE flowchart for hypertension management. Spironolactone can also be introduced at this stage, but only if the patient’s serum potassium is less than 4.5mmol/l, as spironolactone is a potassium-sparing diuretic. Indapamide is not suitable for someone who is already taking a thiazide diuretic like bendroflumethiazide. Furosemide is typically used for hypertension management in patients with heart failure or kidney disease, which is not present in this case. Hydralazine is primarily used for emergency hypertension management or hypertension during pregnancy, not for long-term management.

      NICE Guidelines for Managing Hypertension

      Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of a calcium channel blocker or thiazide-like diuretic in addition to an ACE inhibitor or angiotensin receptor blocker.

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

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

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

    • This question is part of the following fields:

      • Cardiovascular
      30
      Seconds
  • Question 53 - A 55-year-old Caucasian man comes to his GP for a routine check-up. He...

    Incorrect

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

      Your Answer: Losartan

      Correct Answer: Indapamide

      Explanation:

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

      NICE Guidelines for Managing Hypertension

      Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of a calcium channel blocker or thiazide-like diuretic in addition to an ACE inhibitor or angiotensin receptor blocker.

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

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

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

    • This question is part of the following fields:

      • Cardiovascular
      26.7
      Seconds
  • Question 54 - A 48-year-old man comes to the emergency department complaining of sudden onset chest...

    Correct

    • A 48-year-old man comes to the emergency department complaining of sudden onset chest pain. The patient has a medical history of hypertension and is currently taking ramipril. His vital signs are as follows: BP 153/90 mmHg in his right arm and 130/80 in his left arm, heart rate 89/minute, temperature 37.2ºC, respiration rate 17/minute, and oxygen saturation 98% on room air. Upon examination, the patient has absent pulses in his right leg and diminished pulses in his left leg.

      What is the recommended diagnostic test for this patient's presentation?

      Your Answer: CT angiography chest/abdomen/pelvis

      Explanation:

      When a patient presents with symptoms of thoracic aortic dissection and is stable, CT angiography is the preferred diagnostic test. This imaging technique provides a clear view of the aorta and helps plan surgical intervention if necessary. In cases of proximal aortic dissection, inter-arm blood pressure measurements may reveal a difference of over 20 mmHg, with the right arm showing higher pressure due to its proximity to the heart. The absence or reduction of femoral pulses on one or both sides is also a common finding. While a chest x-ray may show signs associated with aortic dissection, it is not specific enough for diagnosis. Transesophageal echocardiography (TOE) is used to confirm the diagnosis if CT angiography is inconclusive or if the patient is unstable. Transthoracic echocardiography (TTE) is less sensitive and specific than TOE for detecting aortic dissection.

      Understanding Aortic Dissection: Classification, Investigation, and Management

      Aortic dissection is a serious medical condition that requires prompt diagnosis and management. It is classified according to the location of the tear in the aorta, with type A affecting the ascending aorta in two-thirds of cases, and type B affecting the descending aorta distal to the left subclavian origin in one-third of cases. The DeBakey classification further divides aortic dissection into type I, which originates in the ascending aorta and propagates to at least the aortic arch, and type II, which is confined to the ascending aorta. Type III originates in the descending aorta and rarely extends proximally but will extend distally.

      To diagnose aortic dissection, imaging studies such as chest x-ray and CT angiography of the chest, abdomen, and pelvis are essential. Transoesophageal echocardiography (TOE) may be more suitable for unstable patients who cannot undergo CT scanning. Management of type A aortic dissection requires surgical intervention, but blood pressure should be controlled to a target systolic of 100-120 mmHg while awaiting surgery. Type B aortic dissection can be managed conservatively with bed rest and IV labetalol to reduce blood pressure and prevent progression.

      Complications of aortic dissection depend on the location of the tear. Backward tears can lead to aortic incompetence/regurgitation and myocardial infarction, while forward tears can cause unequal arm pulses and blood pressure, stroke, and renal failure. Endovascular repair of type B aortic dissection may have a role in the future. It is important to remember that patients may present acutely and be clinically unstable, so the choice of investigations and management should take this into account.

    • This question is part of the following fields:

      • Cardiovascular
      44.3
      Seconds
  • Question 55 - An emergency buzzer sounds on the coronary care unit and you are the...

    Correct

    • An emergency buzzer sounds on the coronary care unit and you are the first doctor to respond. A healthcare assistant on an observation round has found a 72-year-old man unresponsive. You perform a head tilt and chin lift and check for a carotid pulse for 10 seconds while listening for breath sounds, but you detect neither.

      Telemetry attached to the patient shows sinus rhythm at a rate of 110 bpm. The crash team is being summoned, and the crash trolley is being brought to the bedside. You are unaware of any DNACPR orders.

      What is the most appropriate initial step?

      Your Answer: Start chest compressions at a rate of 30:2

      Explanation:

      For a patient in cardiac arrest with a non-shockable rhythm (pulseless-electrical activity), the recommended ratio of chest compressions to ventilation is 30:2. Therefore, the initial action should be to start chest compressions at this rate. Administering 1 mg adrenaline or 300 mg amiodarone is inappropriate as the first step. Adrenaline may be given once chest compressions have started. Amiodarone is only indicated for patients in ventricular fibrillation or pulseless ventricular tachycardia. Delivering a single synchronised DC shock or three quick successive stacked unsynchronised DC shocks followed by 2 minutes of 30:2 compressions is incorrect for a patient in PEA, as these are only appropriate for a shockable rhythm while on telemetry.

      The 2015 Resus Council guidelines for adult advanced life support outline the steps to be taken when dealing with patients with shockable and non-shockable rhythms. For both types of patients, chest compressions are a crucial part of the process, with a ratio of 30 compressions to 2 ventilations. Defibrillation is recommended for shockable rhythms, with a single shock for VF/pulseless VT followed by 2 minutes of CPR. Adrenaline and amiodarone are the drugs of choice for non-shockable rhythms, with adrenaline given as soon as possible and amiodarone administered after 3 shocks for VF/pulseless VT. Thrombolytic drugs should be considered if a pulmonary embolus is suspected. Atropine is no longer recommended for routine use in asystole or PEA. Oxygen should be titrated to achieve saturations of 94-98% following successful resuscitation. The Hs and Ts should be considered as potential reversible causes of cardiac arrest.

    • This question is part of the following fields:

      • Cardiovascular
      77.9
      Seconds
  • Question 56 - You are on-call and reviewing a potassium result. The patient's details are as...

    Correct

    • You are on-call and reviewing a potassium result. The patient's details are as follows:
      Na+ 141 mmol/l
      K+ 6.4 mmol/l
      Bicarbonate 16 mmol/l
      Urea 13.1 mmol/l
      Creatinine 195 µmol/l
      You are uncertain about administering calcium gluconate and decide to seek advice from your senior. She advises you to only give calcium gluconate if there are ECG changes. What ECG changes are most indicative of hyperkalaemia in a patient who is 60 years old?

      Your Answer: Widening of the QRS complex

      Explanation:

      ECG characteristics of hypokalaemia include a prolonged QT interval, prolonged PR interval, and the presence of U waves.

      Understanding Hyperkalaemia: Causes and Symptoms

      Hyperkalaemia is a condition characterized by high levels of potassium in the blood. The regulation of plasma potassium levels is influenced by various factors such as aldosterone, insulin levels, and acid-base balance. When metabolic acidosis occurs, hyperkalaemia may develop as hydrogen and potassium ions compete for exchange with sodium ions across cell membranes and in the distal tubule. ECG changes that may be observed in hyperkalaemia include tall-tented T waves, small P waves, widened QRS leading to a sinusoidal pattern, and asystole.

      There are several causes of hyperkalaemia, including acute kidney injury, metabolic acidosis, Addison’s disease, rhabdomyolysis, and massive blood transfusion. Certain drugs such as potassium-sparing diuretics, ACE inhibitors, angiotensin 2 receptor blockers, spironolactone, ciclosporin, and heparin can also cause hyperkalaemia. It is important to note that beta-blockers can interfere with potassium transport into cells and potentially cause hyperkalaemia in renal failure patients. On the other hand, beta-agonists like Salbutamol are sometimes used as emergency treatment.

      Foods that are high in potassium include salt substitutes, bananas, oranges, kiwi fruit, avocado, spinach, and tomatoes. It is essential to monitor potassium levels in the blood to prevent complications associated with hyperkalaemia. If left untreated, hyperkalaemia can lead to serious health problems such as cardiac arrhythmias and even death.

    • This question is part of the following fields:

      • Cardiovascular
      19.4
      Seconds
  • Question 57 - A 35-year-old woman is found to have a shortened QT interval on her...

    Correct

    • A 35-year-old woman is found to have a shortened QT interval on her ECG. Which medication is the most likely cause?

      Your Answer: Digoxin

      Explanation:

      Effects of Different Anti-Arrhythmic Drugs on QT Interval

      The QT interval is an important measure of cardiac repolarization, and abnormalities in this interval can lead to life-threatening arrhythmias. Different anti-arrhythmic drugs have varying effects on the QT interval.

      Cardiac glycosides such as digoxin and ouabain can shorten the QT interval, even at therapeutic doses. This is due to their ability to shorten the atrial and ventricular refractory periods.

      Class Ia drugs like disopyramide, class Ic drugs like flecainide, and class III drugs like amiodarone and sotalol all prolong the QT interval. Disopyramide can result in a long PR interval, while flecainide can cause a broad QRS or prolonged QT interval. Amiodarone is a class III drug that prolongs the QT interval, and sotalol causes dose-related prolongation of the QT interval.

      β-blockers like atenolol have a neutral effect on the QT interval in patients with a normal QT interval. However, they can act to stabilise the QT interval in patients with long QT syndrome.

      In summary, different anti-arrhythmic drugs have varying effects on the QT interval, and it is important to monitor this interval when prescribing these medications.

    • This question is part of the following fields:

      • Cardiovascular
      10.3
      Seconds
  • Question 58 - What is the recommended next step in managing the blood pressure of a...

    Correct

    • What is the recommended next step in managing the blood pressure of a 42 year old woman with a history of depression and a recent paracetamol overdose who has a manual blood pressure reading of 165/85 mmHg?

      Your Answer: Offer ambulatory blood pressure monitoring

      Explanation:

      The National Institute for Clinical Excellence updated its guideline for hypertension management in 2011, placing emphasis on the use of ambulatory blood pressure monitoring (ABPM) to confirm hypertension in individuals with elevated clinic readings. ABPM involves taking two measurements per hour during waking hours and using the average of at least 14 measurements to confirm a diagnosis of hypertension. Secondary causes of hypertension should be investigated in patients under 40 without traditional risk factors, those with other symptoms of secondary causes, and those with resistant hypertension. Hyperaldosteronism is the most common cause of secondary hypertension, and a trial of spironolactone may be used for both therapeutic and diagnostic purposes. Drug treatment for essential hypertension involves ACE inhibitors for those under 55 and calcium channel blockers for those over 55 or of black African or Caribbean origin. Step 2 involves using both ACE inhibitors and calcium channel blockers, while step 3 adds a thiazide-like diuretic. Further diuretics, beta-blockers, or alpha blockers may be considered in step 4, with expert advice sought. For a more detailed explanation, refer to the provided link.

      NICE released updated guidelines in 2019 for the management of hypertension, building on previous guidelines from 2011. These guidelines aimed to classify hypertension into stages and recommend the use of ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM) to accurately diagnose hypertension. This is important because some patients experience white coat hypertension, where their blood pressure rises in a clinical setting, leading to potential overdiagnosis of hypertension. ABPM and HBPM allow for a more accurate assessment of a patient’s overall blood pressure and can prevent overdiagnosis.

      NICE recommends measuring blood pressure in both arms when considering a diagnosis of hypertension and repeating measurements if there is a difference of more than 20 mmHg between arms. If the blood pressure is >= 140/90 mmHg, NICE suggests offering ABPM or HBPM to confirm the diagnosis. If the blood pressure is >= 180/120 mmHg, referral for specialist assessment is recommended if there are signs of retinal haemorrhage or papilloedema or life-threatening symptoms. If target organ damage is identified, antihypertensive drug treatment may be started immediately.

      ABPM involves taking at least 2 measurements per hour during the person’s usual waking hours and using the average value of at least 14 measurements. If ABPM is not tolerated, HBPM should be offered. HBPM involves taking two consecutive measurements at least 1 minute apart, twice daily for at least 4 days, and using the average value of all remaining measurements.

      Interpreting the results of ABPM/HBPM is important for determining treatment. If the average blood pressure is >= 135/85 mmHg (stage 1 hypertension), treatment may be considered for patients under 80 years of age with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. In 2019, NICE also recommended considering antihypertensive drug treatment for adults under 60 with stage 1 hypertension and an estimated 10-year risk below 10%. If the average blood pressure is >= 150/95 mmHg (stage 2 hypertension), drug treatment should be offered regardless of age.

    • This question is part of the following fields:

      • Cardiovascular
      59.4
      Seconds
  • Question 59 - A 75-year-old man presents to the ambulatory care unit with complaints of tenderness...

    Incorrect

    • A 75-year-old man presents to the ambulatory care unit with complaints of tenderness in his calf. His GP referred him for evaluation. Upon examination, there is no visible swelling, and the leg appears symmetrical to the other leg. However, he experiences tenderness when the deep veins of the calf are palpated. The patient has no significant medical history. What is the initial management option recommended for this patient?

      Your Answer: Arrange a proximal leg vein ultrasound scan with results available within 4 hours

      Correct Answer: Arrange a D dimer test with results available within 4 hours

      Explanation:

      If a patient has a Wells’ score of 1 or less for a suspected DVT, the first step is to arrange a D dimer test with results available within 4 hours, according to NICE guidelines. In this case, the score of 1 is due to localized tenderness along the deep venous system, with no other risk factors present. A proximal leg vein ultrasound scan is not the first-line investigation option for a Wells’ score of 1 or less, and anticoagulant treatment should not be started without a D dimer test. If the D dimer results cannot be obtained within 4 hours, low molecular weight heparin injection may be considered, but therapeutic dose apixaban should not be started without a D dimer test.

      NICE updated their guidelines on the investigation and management of venous thromboembolism (VTE) in 2020. The use of direct oral anticoagulants (DOACs) is recommended as first-line treatment for most people with VTE, including as interim anticoagulants before a definite diagnosis is made. Routine cancer screening is no longer recommended following a VTE diagnosis. The cornerstone of VTE management is anticoagulant therapy, with DOACs being the preferred choice. All patients should have anticoagulation for at least 3 months, with the length of anticoagulation being determined by whether the VTE was provoked or unprovoked.

    • This question is part of the following fields:

      • Cardiovascular
      27.3
      Seconds
  • Question 60 - A 45-year-old woman presents to her General Practitioner (GP) with a 1-day history...

    Incorrect

    • A 45-year-old woman presents to her General Practitioner (GP) with a 1-day history of intermittent chest pains. She states that these started in the afternoon and have gotten worse. The pain is central and seems to improve when she sits on her chair and leans forward. She has a past medical history of hypertension. The GP decides to perform an electrocardiogram (ECG).
      Given the likely diagnosis, which of the following best describes what might be seen on the ECG?
      Select the SINGLE most likely ECG finding from the list below.

      Your Answer: Widespread concave ST-segment elevation

      Correct Answer: Widespread concave ST-segment elevation and PR segment depression

      Explanation:

      Understanding ECG Findings in Acute Pericarditis

      Acute pericarditis is a condition that commonly presents with central pleuritic chest pain, relieved on leaning forward. One of the main ECG findings in acute pericarditis is widespread concave ST-segment elevations with PR-segment depression, which is 85% specific for the condition. Absent P waves are not typically caused by acute pericarditis, and ST-segment elevation in the anterior leads is more suggestive of anterior myocardial infarction. U waves are not characteristic ECG findings in acute pericarditis and are associated with other conditions. Other clinical features of acute pericarditis are largely dependent on the underlying cause. It is important to understand these ECG findings to aid in the diagnosis and management of acute pericarditis.

    • This question is part of the following fields:

      • Cardiovascular
      27.2
      Seconds
  • Question 61 - A 50-year-old man collapses at work with chest pain. He is rushed to...

    Correct

    • A 50-year-old man collapses at work with chest pain. He is rushed to the Emergency Department where he is diagnosed with ST-elevated myocardial infarction. After undergoing successful percutaneous coronary intervention, he is deemed fit for discharge home after a 3-day hospital stay. The patient had no prior medical history and was not taking any regular medications. He also has no known allergies. What is the recommended combination of medications for his discharge?

      Your Answer: Atorvastatin, ramipril, clopidogrel, aspirin and carvedilol

      Explanation:

      After an ACS, it is recommended that all patients receive a combination of medications to reduce the risk of future coronary events. This includes dual antiplatelet therapy (aspirin plus a second antiplatelet agent), an ACE inhibitor, a beta-blocker, and a statin. The correct option for this patient would be a combination of atorvastatin, ramipril, clopidogrel, aspirin, and carvedilol. Atorvastatin is given to reduce cholesterol and prevent further coronary plaque formation, while ramipril is used to prevent cardiac remodeling and preserve left ventricular systolic function. Dual antiplatelet therapy with aspirin and clopidogrel is given to reduce the risk of thrombosis formation after PCI. Finally, beta-blockers such as carvedilol are used to improve prognosis, reduce the risk of arrhythmias, and have cardioprotective effects.

      Myocardial infarction (MI) is a serious condition that requires proper management to prevent further complications. In 2013, NICE released guidelines on the secondary prevention of MI. One of the key recommendations is the use of four drugs: dual antiplatelet therapy (aspirin plus a second antiplatelet agent), ACE inhibitor, beta-blocker, and statin. Patients are also advised to adopt a Mediterranean-style diet and engage in regular exercise. Sexual activity may resume four weeks after an uncomplicated MI, and PDE5 inhibitors may be used six months after the event.

      Most patients with acute coronary syndrome are now given dual antiplatelet therapy, with ticagrelor and prasugrel being the preferred options. The treatment period for these drugs is 12 months, after which they should be stopped. However, this period may be adjusted for patients at high risk of bleeding or further ischaemic events. Additionally, patients with heart failure and left ventricular systolic dysfunction should be treated with an aldosterone antagonist within 3-14 days of the MI, preferably after ACE inhibitor therapy.

      Overall, the NICE guidelines provide a comprehensive approach to the secondary prevention of MI. By following these recommendations, patients can reduce their risk of further complications and improve their overall health outcomes.

    • This question is part of the following fields:

      • Cardiovascular
      28.5
      Seconds
  • Question 62 - You are urgently requested to assess a 62-year-old female patient admitted to the...

    Correct

    • You are urgently requested to assess a 62-year-old female patient admitted to the cardiology ward with complaints of breathing difficulty. During the examination, you observe a raised JVP and bilateral fine crackles to the mid zones. The patient's blood pressure is 100/60 mmHg, and the pulse is irregular and ranges between 140-150. An ECG confirms atrial fibrillation, and there is no prior history of the condition in the patient's notes or previous ECGs. What is the most appropriate course of action for managing this patient?

      Your Answer: Urgent synchronised DC cardioversion

      Explanation:

      Urgent synchronised DC cardioversion is necessary when heart failure is observed as an adverse sign.

      Management of Peri-Arrest Tachycardias

      The Resuscitation Council (UK) guidelines for the management of peri-arrest tachycardias have been simplified in the 2015 update. The previous separate algorithms for broad-complex tachycardia, narrow complex tachycardia, and atrial fibrillation have been replaced by a unified treatment algorithm. After basic ABC assessment, patients are classified as stable or unstable based on the presence of adverse signs such as hypotension, pallor, sweating, confusion, or impaired consciousness. If any of these signs are present, synchronised DC shocks should be given, up to a maximum of three shocks.

      The treatment following this is based on whether the QRS complex is narrow or broad and whether the rhythm is regular or irregular. For broad-complex tachycardia, a loading dose of amiodarone followed by a 24-hour infusion is given if the rhythm is regular. If the rhythm is irregular, expert help should be sought as it could be due to atrial fibrillation with bundle branch block, atrial fibrillation with ventricular pre-excitation, or torsade de pointes.

      For narrow-complex tachycardia, vagal manoeuvres followed by IV adenosine are given if the rhythm is regular. If unsuccessful, atrial flutter is considered, and rate control is achieved with beta-blockers. If the rhythm is irregular, it is likely due to atrial fibrillation, and electrical or chemical cardioversion is considered if the onset is less than 48 hours. Beta-blockers are usually the first-line treatment for rate control unless contraindicated. The full treatment algorithm can be found on the Resuscitation Council website.

    • This question is part of the following fields:

      • Cardiovascular
      99.3
      Seconds
  • Question 63 - Samantha, a 56-year-old teacher, visits you for a check-up regarding her angina. Despite...

    Incorrect

    • Samantha, a 56-year-old teacher, visits you for a check-up regarding her angina. Despite taking the highest dosage of bisoprolol, she experiences chest pain during physical activity, which hinders her daily routine as she frequently needs to take breaks and rest after walking short distances. Her pain never occurs while at rest, and she has no known allergies or drug sensitivities. What is the recommended course of action for managing Samantha's condition?

      Your Answer: Add verapamil

      Correct Answer: Add amlodipine

      Explanation:

      According to NICE guidelines (2019), if a beta-blocker is not effectively controlling angina, a long-acting dihydropyridine calcium-channel blocker (CCB) like amlodipine should be added. It is important to ensure that the patient is taking the highest tolerated dose of their current medications before adding new ones.

      Ramipril is not the best treatment option for this patient as there is no evidence of hypertension in their medical history. While ACE inhibitors like ramipril can be effective in preventing myocardial infarction and stroke in patients with angina and hypertension, they are not indicated in this case.

      Verapamil is a CCB that can be used to manage angina, but it should not be used in combination with a beta-blocker as this can increase the risk of severe bradycardia and heart failure.

      As the patient is not displaying any signs of unstable angina, such as pain at rest or rapidly progressing symptoms, admission to the emergency department is not necessary.

      If there is evidence of extensive ischaemia on an electrocardiograph (ECG) or the patient is not responding well to an optimised drug treatment, referral to cardiology for angioplasty may be necessary.

      Angina pectoris is a condition that can be managed through various methods, including lifestyle changes, medication, percutaneous coronary intervention, and surgery. In 2011, NICE released guidelines for the management of stable angina. Medication is an important aspect of treatment, and all patients should receive aspirin and a statin unless there are contraindications. Sublingual glyceryl trinitrate can be used to abort angina attacks. The first-line medication should be either a beta-blocker or a calcium channel blocker, depending on the patient’s comorbidities, contraindications, and preferences. If a calcium channel blocker is used as monotherapy, a rate-limiting one such as verapamil or diltiazem should be used. If used in combination with a beta-blocker, a longer-acting dihydropyridine calcium channel blocker should be used. Beta-blockers should not be prescribed concurrently with verapamil due to the risk of complete heart block. If the initial treatment is not effective, medication should be increased to the maximum tolerated dose. If a patient is still symptomatic after monotherapy with a beta-blocker, a calcium channel blocker can be added, and vice versa. If a patient cannot tolerate the addition of a calcium channel blocker or a beta-blocker, other drugs such as long-acting nitrates, ivabradine, nicorandil, or ranolazine can be considered. Nitrate tolerance is a common issue, and patients who take standard-release isosorbide mononitrate should use an asymmetric dosing interval to maintain a daily nitrate-free time of 10-14 hours to minimize the development of nitrate tolerance. This effect is not seen in patients who take once-daily modified-release isosorbide mononitrate. If a patient is taking both a beta-blocker and a calcium-channel blocker, a third drug should only be added while awaiting assessment for PCI or CABG.

    • This question is part of the following fields:

      • Cardiovascular
      47.4
      Seconds
  • Question 64 - Left bundle branch block is associated with which one of the following conditions?
    ...

    Correct

    • Left bundle branch block is associated with which one of the following conditions?

      Your Answer: Ischaemic heart disease

      Explanation:

      ECG Findings in Various Cardiovascular Conditions

      New-onset left bundle branch block may indicate ischaemic heart disease and could be a sign of STEMI if the patient’s symptoms match the diagnosis. Pericarditis typically causes widespread ST elevation on an ECG. Mitral stenosis can lead to left atrial enlargement and potentially atrial fibrillation. Pulmonary embolism often results in a right bundle branch block or a right ventricular strain pattern of S1Q3T3. Tricuspid stenosis can also cause right ventricular strain. It’s worth noting that mitral stenosis, tricuspid stenosis, and secondary pulmonary hypertension due to PE are associated with right ventricular strain and hypertrophy with partial or complete right bundle branch block, while pericarditis is not typically associated with bundle branch block.

    • This question is part of the following fields:

      • Cardiovascular
      12.9
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  • Question 65 - A 56-year-old man is scheduled for the removal of three decayed teeth. He...

    Correct

    • A 56-year-old man is scheduled for the removal of three decayed teeth. He has a medical history of type 2 diabetes mellitus and a mechanical aortic valve replacement for aortic stenosis. What prophylaxis should he receive to prevent infective endocarditis before the procedure?

      Your Answer: No prophylaxis

      Explanation:

      Infective endocarditis is a serious infection of the heart lining and valves. The 2008 guidelines from NICE have changed the list of procedures for which antibiotic prophylaxis is recommended. According to NICE, dental procedures, gastrointestinal, genitourinary, and respiratory tract procedures do not require prophylaxis. However, if a person at risk of infective endocarditis is receiving antimicrobial therapy because they are undergoing a gastrointestinal or genitourinary procedure at a site where there is a suspected infection, they should be given an antibiotic that covers organisms that cause infective endocarditis. It is important to note that these recommendations differ from the American Heart Association/European Society of Cardiology guidelines, which still advocate antibiotic prophylaxis for high-risk patients undergoing dental procedures.

      The guidelines suggest that any episodes of infection in people at risk of infective endocarditis should be investigated and treated promptly to reduce the risk of endocarditis developing. It is crucial to follow these guidelines to prevent the development of infective endocarditis, which can lead to severe complications and even death. It is also important to note that these guidelines may change over time as new research and evidence become available. Therefore, healthcare professionals should stay up-to-date with the latest recommendations to provide the best possible care for their patients.

    • This question is part of the following fields:

      • Cardiovascular
      10.2
      Seconds
  • Question 66 - An aged patient in the oncology unit experiences a cardiac arrest. You initiate...

    Correct

    • An aged patient in the oncology unit experiences a cardiac arrest. You initiate compressions and notify the resuscitation team. Upon rhythm assessment, VT is detected. Following three rounds of CPR and multiple shocks, which two medications are recommended in the ALS protocol?

      Your Answer: Amiodarone 300mg and adrenaline 1mg

      Explanation:

      During advanced ALS, the recommended dose of adrenaline to administer is 1mg. If the patient is identified in the hospital, they should receive a minimum shock of 150 joules (unless the defibrillator model specifies otherwise). Compressions at a rate of 30:2 should be resumed for 2 minutes, followed by reassessment of the rhythm. If VF or pVT persists, a second shock should be given. Repeat the previous steps until the third shock, at which point 1mg IV of adrenaline and 300 mg IV of amiodarone should be administered while continuing CPR. Afterward, 1mg of adrenaline should be given after every other shock. Consider administering a second dose of amiodarone after a total of 5 defibrillation attempts if it is available. If amiodarone is not available, lidocaine can be used.

      The 2015 Resus Council guidelines for adult advanced life support outline the steps to be taken when dealing with patients with shockable and non-shockable rhythms. For both types of patients, chest compressions are a crucial part of the process, with a ratio of 30 compressions to 2 ventilations. Defibrillation is recommended for shockable rhythms, with a single shock for VF/pulseless VT followed by 2 minutes of CPR. Adrenaline and amiodarone are the drugs of choice for non-shockable rhythms, with adrenaline given as soon as possible and amiodarone administered after 3 shocks for VF/pulseless VT. Thrombolytic drugs should be considered if a pulmonary embolus is suspected. Atropine is no longer recommended for routine use in asystole or PEA. Oxygen should be titrated to achieve saturations of 94-98% following successful resuscitation. The Hs and Ts should be considered as potential reversible causes of cardiac arrest.

    • This question is part of the following fields:

      • Cardiovascular
      29.3
      Seconds
  • Question 67 - A 42-year-old woman presented with swelling in her feet and mentioned that she...

    Correct

    • A 42-year-old woman presented with swelling in her feet and mentioned that she uses two pillows while sleeping. What is the most suitable initial investigation?

      Your Answer: Plasma NT-proBNP

      Explanation:

      Diagnostic Tests for Suspected Heart Failure

      When a patient presents with symptoms of peripheral edema and orthopnea, heart failure is a likely diagnosis. To confirm this, NICE guidelines recommend using N-terminal pro-B-type natriuretic peptide (NT-proBNP) as an initial investigation. A level below 400 ng/litre makes heart failure unlikely, while levels between 400 and 2,000 ng/litre require referral for specialist assessment within 6 weeks. Levels above 2,000 ng/litre require referral within 2 weeks. An echocardiogram should be performed to quantify ventricular function if the ECG and NT-proBNP are abnormal. Blood cultures can also be useful for detecting systemic infection or endocarditis. An exercise tolerance test is more appropriate for suspected coronary artery disease. Finally, rheumatoid factor is a non-specific test for autoimmune conditions.

    • This question is part of the following fields:

      • Cardiovascular
      21.4
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  • Question 68 - A 65-year-old woman presents with difficulty breathing and feeling lightheaded. During the examination,...

    Correct

    • A 65-year-old woman presents with difficulty breathing and feeling lightheaded. During the examination, an irregularly irregular pulse is noted. An ECG taken at the time shows the absence of p waves. What medical condition in her past could be responsible for her symptoms?

      Your Answer: Hyperthyroidism

      Explanation:

      Common Endocrine Disorders and their Cardiac Manifestations

      Endocrine disorders can have significant effects on the cardiovascular system, including the development of arrhythmias. Atrial fibrillation is a common arrhythmia that can be caused by hyperthyroidism, which should be tested for in patients presenting with this condition. Other signs of thyrotoxicosis include sinus tachycardia, physiological tremor, lid lag, and lid retraction. Graves’ disease, a common cause of hyperthyroidism, can also present with pretibial myxoedema, proptosis, chemosis, and thyroid complex ophthalmoplegia.

      Hyperparathyroidism can cause hypercalcemia, which may present with non-specific symptoms such as aches and pains, dehydration, fatigue, mood disturbance, and constipation. It can also cause renal stones. Hypothyroidism, on the other hand, may cause bradycardia and can be caused by Hashimoto’s thyroiditis, subacute thyroiditis, iodine deficiency, or iatrogenic factors such as post-carbimazole treatment, radio-iodine, and thyroidectomy. Drugs such as lithium and amiodarone can also cause hypothyroidism.

      Cushing syndrome, a disorder caused by excess cortisol production, is not typically associated with arrhythmias. Type 1 diabetes mellitus, another endocrine disorder, also does not typically present with arrhythmias.

      In summary, it is important to consider endocrine disorders as potential causes of cardiac manifestations, including arrhythmias. Proper diagnosis and management of these conditions can help prevent serious cardiovascular complications.

    • This question is part of the following fields:

      • Cardiovascular
      14.3
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  • Question 69 - A 42-year-old woman who is six weeks pregnant presents to the Cardiovascular Clinic...

    Correct

    • A 42-year-old woman who is six weeks pregnant presents to the Cardiovascular Clinic with a swollen right leg. Doppler studies confirm a deep vein thrombosis (DVT). She has no signs or symptoms of a pulmonary embolism (PE) and is haemodynamically stable. What is the most appropriate management choice in this case?

      Your Answer: Start subcutaneous low molecular weight heparin (LMWH) throughout pregnancy and change to warfarin in the postpartum period

      Explanation:

      Treatment Options for Deep Vein Thrombosis in Pregnancy

      Start subcutaneous low molecular weight heparin (LMWH) throughout pregnancy and change to warfarin in the postpartum period: LMWH is recommended for the treatment of DVT during pregnancy. Treatment should be continued for at least three months and until six weeks postpartum. Warfarin can be used after day five of the postpartum period. Both LMWH and warfarin are safe to use while breastfeeding.

      Elastic band compression of the affected leg, bedrest, and foot elevation: These measures have no benefit in treating DVT and may even increase the risk of developing a pulmonary embolism (PE) or another DVT.

      Commence intravenous (IV) heparin: IV heparin can be used for the treatment of a shocked patient with PE if thrombolysis is not possible. It should not be used for DVT alone.

      Oral anticoagulation with warfarin daily throughout pregnancy and the postpartum period: Warfarin is not recommended during pregnancy as it can cross the placenta and increase the risk of congenital malformations and bleeding.

      Aspirin 300 mg daily throughout pregnancy and the postpartum period: Aspirin is not effective in treating DVT or PE as it is an antiplatelet drug, not an anticoagulant.

      Treatment Options for Deep Vein Thrombosis in Pregnancy

    • This question is part of the following fields:

      • Cardiovascular
      34.5
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  • Question 70 - An 82-year-old woman presents to the Emergency Department after experiencing a blackout while...

    Correct

    • An 82-year-old woman presents to the Emergency Department after experiencing a blackout while shopping. Upon examination, she appears alert and oriented, and her vital signs are stable. Her CBG level is 5.8 mmol/l, and her pulse is irregular with a low volume at 89 beats per minute. Her blood pressure is 145/120 mmHg while lying and standing. There is no raised jugular venous pressure, and her apex beat is forceful but undisplaced. Heart sounds reveal a soft S2 and a soft ejection systolic murmur loudest in the right second intercostal space, with a possible fourth heart sound heard. Chest examination reveals occasional bibasal crackles that clear with coughing, and there is no peripheral edema. Based on these findings, what is the most likely cause of her collapse?

      Your Answer: Aortic stenosis

      Explanation:

      Understanding Aortic Stenosis and Differential Diagnosis

      Aortic stenosis is a condition that presents with symptoms of left ventricular failure, angina, and potential collapse or blackout if the stenosis is critical. A low-volume pulse, narrow pulse pressure, slow-rising carotid pulse, undisplaced, sustained/forceful apex beat, soft or absent A2, ejection systolic murmur + fourth heart sound, and pulmonary edema are significant signs of aortic stenosis.

      It is important to differentiate aortic stenosis from other conditions such as mitral regurgitation, aortic regurgitation, mitral stenosis, and mixed mitral and aortic valve disease. Mitral regurgitation causes a pan-systolic murmur radiating to the axilla, while aortic regurgitation causes an early diastolic murmur and a collapsing pulse. Mitral stenosis causes a mid-diastolic murmur with a characteristic opening snap. There is no definitive evidence of mitral valve disease in this clinical scenario.

      Understanding the signs and symptoms of aortic stenosis and differentiating it from other conditions is crucial for proper diagnosis and treatment.

    • This question is part of the following fields:

      • Cardiovascular
      43
      Seconds
  • Question 71 - A 45-year-old woman had an anterior myocardial infarction. She has a body mass...

    Correct

    • A 45-year-old woman had an anterior myocardial infarction. She has a body mass index (BMI) of 30 kg/m2, smokes 10 cigarettes per day and admits to a high-sugar diet and minimal exercise.
      Which of the following non-pharmacological interventions will be most helpful in reducing her risk for a future ischaemic event?

      Your Answer: Stopping smoking

      Explanation:

      Reducing the Risk of Vascular Events: Lifestyle Interventions

      Smoking, high salt intake, poor diet, lack of exercise, and obesity are all risk factors for vascular events such as heart attacks and strokes. However, making lifestyle changes can significantly reduce the risk of these events.

      Stopping smoking is the most effective non-pharmacological intervention, as it reduces the risk of heart disease by 2-3 times compared to those who continue to smoke.

      Reducing salt intake to 3-6 g/day can also help, as both high and low salt intake can increase the risk of vascular events.

      Improving diet by controlling calorie intake can lead to weight loss, improved blood sugar control, and better lipid profiles.

      Regular exercise, such as 30 minutes of activity five times a week, can lower the risk of vascular events by 30%.

      Finally, weight reduction is important, as obesity increases the risk of heart attacks and strokes at a younger age and can lead to higher mortality rates.

      Overall, making these lifestyle changes can significantly reduce the risk of vascular events and improve overall health.

    • This question is part of the following fields:

      • Cardiovascular
      9.2
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  • Question 72 - A 63-year-old male with a recent myocardial infarction experiences ventricular fibrillation while in...

    Correct

    • A 63-year-old male with a recent myocardial infarction experiences ventricular fibrillation while in the coronary care unit. The heart monitor records this event. An emergency call is made and a defibrillator is quickly brought to the scene. What is the best course of action to take?

      Your Answer: Administer three successive shocks, then commence CPR

      Explanation:

      In a witnessed cardiac arrest with VF/VT rhythm, up to three quick successive shocks should be given before starting chest compressions. This is regarded as the first shock in the ALS algorithm. Adrenaline should be given every 3-5 minutes and a praecordial thump should only be used if a defibrillator is not available. Commencing CPR after just one shock would miss the opportunity to deliver three rapid shocks.

      The 2015 Resus Council guidelines for adult advanced life support outline the steps to be taken when dealing with patients with shockable and non-shockable rhythms. For both types of patients, chest compressions are a crucial part of the process, with a ratio of 30 compressions to 2 ventilations. Defibrillation is recommended for shockable rhythms, with a single shock for VF/pulseless VT followed by 2 minutes of CPR. Adrenaline and amiodarone are the drugs of choice for non-shockable rhythms, with adrenaline given as soon as possible and amiodarone administered after 3 shocks for VF/pulseless VT. Thrombolytic drugs should be considered if a pulmonary embolus is suspected. Atropine is no longer recommended for routine use in asystole or PEA. Oxygen should be titrated to achieve saturations of 94-98% following successful resuscitation. The Hs and Ts should be considered as potential reversible causes of cardiac arrest.

    • This question is part of the following fields:

      • Cardiovascular
      11.5
      Seconds
  • Question 73 - A 50-year-old woman with a history of hypertension and hypercholesterolaemia presents with sudden...

    Correct

    • A 50-year-old woman with a history of hypertension and hypercholesterolaemia presents with sudden shortness of breath one hour after undergoing primary percutaneous intervention for an anterior ST-elevation myocardial infarction. The procedure was successful and radial access was used. She initially appeared stable and a bedside echocardiogram showed normal left ventricular function. However, on examination, she appears unwell with diaphoresis, tachypnea, hypotension (80/42 mmHg), tachycardia (111/minute), and elevated JVP. There are no signs of peripheral oedema or deep venous thrombosis. What is the most urgent intervention that could save her life?

      Your Answer: Pericardiocentesis

      Explanation:

      Cardiac tamponade is suggested by the presence of Beck’s triad, which includes falling blood pressure, rising jugular venous pulse, and muffled heart sounds. Therefore, cardiogenic shock is unlikely as the patient underwent successful revascularization and had a normal echocardiogram post-procedure. While inotropes may provide temporary support for low blood pressure, they are not a curative option in this case. Sepsis is not the cause of hypotension as it is typically associated with a fever, bounding pulse, and warm extremities, and the jugular venous pulse would not be elevated. Intravenous antibiotics are therefore not the correct answer. Hypovolemia is also not associated with an elevated jugular venous pulse, so intravenous fluids are not the correct answer. Additionally, the use of radial access makes a retroperitoneal hematoma less likely. The correct answer is pericardiocentesis, as the clinical features suggest cardiac tamponade, which is a known complication of primary percutaneous intervention in myocardial infarction.

      Cardiac tamponade is a condition where there is an accumulation of fluid in the pericardial sac, which puts pressure on the heart. This can lead to a range of symptoms, including hypotension, raised JVP, muffled heart sounds, dyspnoea, tachycardia, and pulsus paradoxus. One of the key features of cardiac tamponade is the absence of a Y descent on the JVP, which is due to limited right ventricular filling. Other diagnostic criteria include Kussmaul’s sign and electrical alternans on an ECG. Constrictive pericarditis is a similar condition, but it can be distinguished from cardiac tamponade by the presence of an X and Y descent on the JVP, the absence of pulsus paradoxus, and the presence of pericardial calcification on a chest X-ray. The management of cardiac tamponade involves urgent pericardiocentesis to relieve the pressure on the heart.

    • This question is part of the following fields:

      • Cardiovascular
      59.7
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  • Question 74 - A 42-year-old man presents to the Emergency Department (ED) with a history of...

    Correct

    • A 42-year-old man presents to the Emergency Department (ED) with a history of fainting. He reports feeling lightheaded while jogging. His father recently passed away suddenly due to a heart condition. Upon examination, he has an irregular pulse, a forceful cardiac impulse, and a mid-systolic murmur.

      What is the most probable diagnosis? Choose the ONE best option from the list below.

      Your Answer: Hypertrophic cardiomyopathy (HCM)

      Explanation:

      Hypertrophic cardiomyopathy (HCM) is a genetic disorder with autosomal dominant transmission that is the most common form of inherited cardiomyopathy. It has a prevalence of about 100 per 100,000 and can present with symptoms similar to aortic stenosis, but with a jerky pulse. Sudden death can be the first symptom, especially during or after physical activity. Risk factors for sudden death in HCM include a history of previous cardiac arrest or sustained ventricular tachycardia, recurrent syncope, adverse genotype and/or family history, exercise-induced hypotension, multiple episodes of non-sustained ventricular tachycardia on ambulatory ECG, and a marked increase in the thickness of the left ventricular wall. Dilated cardiomyopathy is the most common form of non-ischaemic cardiomyopathy, but given the patient’s family history, jerky pulse, and collapse on exercise, it is not the most likely cause. Mitral valve prolapse tends to present with palpitations, dyspnoea, low BMI, chest pain, and syncope, with a mid-systolic click followed by a late systolic murmur. Aortic stenosis can cause dizziness, syncope, and angina, but the family history makes HCM more likely than AS. Pericarditis tends to cause central chest pain that is relieved by leaning forward and worsened by coughing or straining.

    • This question is part of the following fields:

      • Cardiovascular
      32.2
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  • Question 75 - A 49-year-old man is being evaluated at the smoking cessation clinic. Is there...

    Correct

    • A 49-year-old man is being evaluated at the smoking cessation clinic. Is there any medical condition that would make it inappropriate to prescribe bupropion for him?

      Your Answer: Epilepsy

      Explanation:

      Reduced seizure threshold is a contraindication for the use of bupropion in patients with epilepsy.

      NICE guidance recommends offering nicotine replacement therapy (NRT), varenicline, or bupropion to patients for smoking cessation, with no preference for one medication over another. NRT should be offered in combination for those with high nicotine dependence or inadequate response to single forms. Varenicline should be started a week before the target stop date and monitored for adverse effects, including nausea and suicidal behavior. Bupropion should also be started before the target stop date and is contraindicated in epilepsy, pregnancy, and breastfeeding. Pregnant women should be tested for smoking and referred to NHS Stop Smoking Services, with first-line interventions being cognitive behavior therapy, motivational interviewing, or structured self-help and support. NRT may be used if other measures fail, but varenicline and bupropion are contraindicated.

    • This question is part of the following fields:

      • Cardiovascular
      20.7
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  • Question 76 - Which one of the following patients should not be prescribed a statin without...

    Correct

    • Which one of the following patients should not be prescribed a statin without any contraindication?

      Your Answer: A 57-year-old man with well controlled diabetes mellitus type 2 with a 10-year cardiovascular risk of 8%

      Explanation:

      Statins are drugs that inhibit the action of an enzyme called HMG-CoA reductase, which is responsible for producing cholesterol in the liver. However, they can cause some adverse effects such as myopathy, which includes muscle pain, weakness, and damage, and liver impairment. Myopathy is more common in lipophilic statins than in hydrophilic ones. Statins may also increase the risk of intracerebral hemorrhage in patients who have had a stroke before. Therefore, they should be avoided in these patients. Statins should not be taken during pregnancy and should be stopped if the patient is taking macrolides.

      Statins are recommended for people with established cardiovascular disease, those with a 10-year cardiovascular risk of 10% or more, and patients with type 2 diabetes mellitus. Patients with type 1 diabetes mellitus who were diagnosed more than 10 years ago, are over 40 years old, or have established nephropathy should also take statins. It is recommended to take statins at night as this is when cholesterol synthesis takes place. Atorvastatin 20mg is recommended for primary prevention, and the dose should be increased if non-HDL has not reduced for 40% or more. Atorvastatin 80 mg is recommended for secondary prevention.

    • This question is part of the following fields:

      • Cardiovascular
      54.8
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  • Question 77 - A 75-year-old man has isolated systolic hypertension. He also has angina, gout and...

    Correct

    • A 75-year-old man has isolated systolic hypertension. He also has angina, gout and peripheral vascular disease.
      Which of the following antihypertensives is best suited for him initially?

      Your Answer: Amlodipine

      Explanation:

      Antihypertensive Medications and NICE Guidelines

      NICE guidelines recommend different antihypertensive medications based on age and ethnicity. For those under 55, an ACE inhibitor or ARB is advised, while calcium channel blockers are recommended for those over 55 and of Afro-Caribbean origin. Thiazide diuretics, such as bendroflumethiazide, are only third-line treatments and contraindicated in gout. Furosemide is not indicated for hypertension but can be used for oedema in heart failure. Beta blockers, like atenolol, are relatively contraindicated in peripheral vascular disease and not recommended for hypertension treatment. ACE inhibitors, such as ramipril, are the first-line treatment for patients under 55, while calcium channel blockers are advised for those over 55, like an 80-year-old patient.

    • This question is part of the following fields:

      • Cardiovascular
      23.2
      Seconds
  • Question 78 - A 58-year-old man presents to the emergency department with chest pain that has...

    Incorrect

    • A 58-year-old man presents to the emergency department with chest pain that has been radiating to his neck and left arm for the past 3 hours. An ECG reveals ST depression in the inferior leads, and a troponin test is ordered. The patient is given aspirin and sublingual nitrates, and a non-ST elevated myocardial infarction is suspected. The physician conducts a risk assessment to determine the patient's 6-month mortality.

      What factors are taken into account by the doctor during this calculation?

      Your Answer: Age, ECG, heart rate, lactate

      Correct Answer: Age, ECG, troponin, renal function

      Explanation:

      To determine the management of NSTEMI, doctors use a risk assessment score such as GRACE. This score takes into account various factors such as age, ECG, troponin, and renal function, as well as blood pressure, heart rate, and whether the patient experienced a cardiac arrest upon presentation. Renal function is particularly important to consider as it is often affected during an AMI. However, lactate and liver function tests are not included in the GRACE score as they are not typically affected by an MI.

      Managing Acute Coronary Syndrome: A Summary of NICE Guidelines

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

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

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

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

    • This question is part of the following fields:

      • Cardiovascular
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  • Question 79 - A 70-year-old man has been taking warfarin for 2 years due to paroxysmal...

    Incorrect

    • A 70-year-old man has been taking warfarin for 2 years due to paroxysmal atrial fibrillation. He recently underwent DC cardioversion and is now in sinus rhythm after consulting with his cardiologist. His CHAD-VASC score is 4. Assuming he remains in sinus rhythm, what is the best course of action for his anticoagulation?

      Your Answer: Continue anticoagulation for six months then stop

      Correct Answer: Continue anticoagulation lifelong

      Explanation:

      Anticoagulation should be continued long-term, even if sinus rhythm is maintained, following elective DC cardioversion for AF in high-risk patients. The correct answer is to continue anticoagulation lifelong, with regular evaluation of bleeding risk. The options of continuing anticoagulation for 4 weeks or 6 months then stopping are incorrect for this patient who has a high CHAD-VASC score. One week of low molecular weight heparin is not the appropriate answer in this case, although it may be used for thromboprophylaxis in some post-surgical patients.

      Atrial Fibrillation and Cardioversion: Elective Procedure for Rhythm Control

      Cardioversion is a medical procedure used in atrial fibrillation (AF) to restore the heart’s normal rhythm. There are two scenarios where cardioversion may be used: as an emergency if the patient is haemodynamically unstable, or as an elective procedure where a rhythm control strategy is preferred. In the elective scenario, cardioversion can be performed either electrically or pharmacologically. Electrical cardioversion is synchronised to the R wave to prevent delivery of a shock during the vulnerable period of cardiac repolarisation when ventricular fibrillation can be induced.

      According to the 2014 NICE guidelines, rate or rhythm control should be offered if the onset of the arrhythmia is less than 48 hours, and rate control should be started if it is more than 48 hours or is uncertain. If the AF is definitely of less than 48 hours onset, patients should be heparinised and may be cardioverted using either electrical or pharmacological means. However, if the patient has been in AF for more than 48 hours, anticoagulation should be given for at least 3 weeks prior to cardioversion. An alternative strategy is to perform a transoesophageal echo (TOE) to exclude a left atrial appendage (LAA) thrombus. If excluded, patients may be heparinised and cardioverted immediately.

      NICE recommends electrical cardioversion in this scenario, rather than pharmacological. If there is a high risk of cardioversion failure, it is recommended to have at least 4 weeks of amiodarone or sotalol prior to electrical cardioversion. Following electrical cardioversion, patients should be anticoagulated for at least 4 weeks. After this time, decisions about anticoagulation should be taken on an individual basis depending on the risk of recurrence.

    • This question is part of the following fields:

      • Cardiovascular
      32.9
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  • Question 80 - A 50-year-old man comes to the clinic complaining of palpitations that started about...

    Incorrect

    • A 50-year-old man comes to the clinic complaining of palpitations that started about 30 minutes ago. He mentions having a stressful day at work, but there doesn't seem to be any other obvious trigger. He denies experiencing any chest pain or difficulty breathing. Upon conducting an ECG, a regular tachycardia of 180 bpm with a QRS duration of 0.10s is observed. His blood pressure is 106/70 mmHg, and his oxygen saturation is 98% on room air. Despite performing the Valsalva manoeuvre, there is no effect on the rhythm. What is the most appropriate next step?

      Your Answer: Intravenous labetalol

      Correct Answer: Intravenous adenosine

      Explanation:

      In cases of haemodynamically stable patients with SVT who do not respond to vagal manoeuvres, the recommended course of action is to administer adenosine.

      Understanding Supraventricular Tachycardia

      Supraventricular tachycardia (SVT) is a type of tachycardia that originates above the ventricles. It is commonly associated with paroxysmal SVT, which is characterized by sudden onset of a narrow complex tachycardia, usually an atrioventricular nodal re-entry tachycardia (AVNRT). Other causes include atrioventricular re-entry tachycardias (AVRT) and junctional tachycardias.

      When it comes to acute management, vagal maneuvers such as the Valsalva maneuver or carotid sinus massage can be used. Intravenous adenosine is also an option, with a rapid IV bolus of 6mg given initially, followed by 12mg and then 18mg if necessary. However, adenosine is contraindicated in asthmatics, and verapamil may be a better option for them. Electrical cardioversion is another option.

      To prevent episodes of SVT, beta-blockers can be used. Radio-frequency ablation is also an option. It is important to work with a healthcare provider to determine the best course of treatment for each individual case.

      Overall, understanding SVT and its management options can help individuals with this condition better manage their symptoms and improve their quality of life.

    • This question is part of the following fields:

      • Cardiovascular
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  • Question 81 - Which of the following tests would be most beneficial in diagnosing heart failure?...

    Correct

    • Which of the following tests would be most beneficial in diagnosing heart failure?

      Your Answer: B-type natriuretic peptide (BNP)

      Explanation:

      Understanding Cardiac Biomarkers: Importance of BNP in Heart Failure Diagnosis

      When it comes to diagnosing heart failure, healthcare professionals rely on various cardiac biomarkers to aid in their assessment. Among these biomarkers, B-type natriuretic peptide (BNP) is considered the primary investigation according to the National Institute for Health and Care Excellence (NICE) guidelines.

      Unlike other biomarkers such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), BNP is specific to heart failure and is not affected by inflammation. On the other hand, troponin T is useful in diagnosing acute coronary syndromes, while creatine phosphokinase is primarily used to detect muscle breakdown and rhabdomyolysis.

      It is important to note that certain factors such as obesity and medications like angiotensin-converting enzyme (ACE) inhibitors, and angiotensin receptor blockers (ARBs) can falsely lower BNP levels. Therefore, if BNP levels are elevated, patients should be referred for an echocardiogram to confirm the diagnosis of heart failure.

      In summary, understanding the role of cardiac biomarkers such as BNP in heart failure diagnosis is crucial in providing accurate and timely treatment for patients.

    • This question is part of the following fields:

      • Cardiovascular
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  • Question 82 - You are asked by the nursing staff to review an elderly patient in...

    Correct

    • You are asked by the nursing staff to review an elderly patient in recovery overnight. As you arrive, the nurse looking after the patient informs you that she is just going to get a bag of fluid for him.
      On examination, the patient is unresponsive with an obstructed airway (snoring). You notice on the monitor that his heart rate is 33 beats per minute (bpm) and blood pressure 89/60 mmHg. His saturation probe has fallen off.
      What is the most appropriate immediate management option?

      Your Answer: Call for help and maintain the airway with a jaw thrust and deliver 15 litres of high-flow oxygen

      Explanation:

      Managing a Patient with Bradycardia and Airway Obstruction: Priorities and Interventions

      When faced with a patient who is unresponsive and has both an obstructed airway and bradycardia, it is crucial to prioritize interventions based on the A-E assessment. The first priority is to maintain the airway with a jaw thrust and deliver high-flow oxygen. Once help is called, the patient’s response is monitored, and if bradycardia persists, atropine is given in 500 µg boluses IV. If the airway obstruction cannot be managed with simple measures or non-definitive airways, re-intubation may be necessary. In cases where atropine is ineffective, an isoprenaline infusion may be considered. While a second IV access line may be beneficial, it is not a priority in this situation. By following these interventions, the patient’s condition can be stabilized and managed effectively.

    • This question is part of the following fields:

      • Cardiovascular
      43.4
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  • Question 83 - After expressing discomfort in their chest, a 75-year-old patient suddenly collapses on the...

    Correct

    • After expressing discomfort in their chest, a 75-year-old patient suddenly collapses on the surgical ward with no detectable pulse. The medical team initiates cardiopulmonary resuscitation (CPR) and calls for immediate assistance.
      Once the defibrillator is connected, the team pauses to check the rhythm. Although there is organised electrical activity, there is still no pulse or signs of life.
      In addition to continuing CPR with a ratio of 30 compressions to 2 breaths, what other actions should the team take at this stage?

      Your Answer: Give intravenous adrenaline

      Explanation:

      In the case of pulseless electrical activity, which is a non-shockable rhythm, the ALS algorithm requires the administration of adrenaline as soon as intravascular access is achieved. This should be done immediately after the rhythm check, following two more minutes of CPR. The recommended dose is 1mg IV, which should be repeated every 3-5 minutes. It is important to note that intramuscular adrenaline is not appropriate for cardiac arrest, and IV amiodarone is not indicated for non-shockable rhythms. While it is correct to avoid shocking the patient, it is incorrect to delay drug administration until the next rhythm check. The most recent Resuscitation Council Guidelines (2021) support the immediate administration of adrenaline in non-shockable rhythms.

      The 2015 Resus Council guidelines for adult advanced life support outline the steps to be taken when dealing with patients with shockable and non-shockable rhythms. For both types of patients, chest compressions are a crucial part of the process, with a ratio of 30 compressions to 2 ventilations. Defibrillation is recommended for shockable rhythms, with a single shock for VF/pulseless VT followed by 2 minutes of CPR. Adrenaline and amiodarone are the drugs of choice for non-shockable rhythms, with adrenaline given as soon as possible and amiodarone administered after 3 shocks for VF/pulseless VT. Thrombolytic drugs should be considered if a pulmonary embolus is suspected. Atropine is no longer recommended for routine use in asystole or PEA. Oxygen should be titrated to achieve saturations of 94-98% following successful resuscitation. The Hs and Ts should be considered as potential reversible causes of cardiac arrest.

    • This question is part of the following fields:

      • Cardiovascular
      25.2
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  • Question 84 - A 62-year-old man visits his GP complaining of recurring central chest pain during...

    Incorrect

    • A 62-year-old man visits his GP complaining of recurring central chest pain during physical activity. He reports no chest pain while at rest. The patient was diagnosed with angina six months ago and has been taking verapamil and GTN spray. His medical history includes hypertension, asthma, and osteoarthritis of the right knee. What medication should the doctor prescribe?

      Your Answer: Bisoprolol

      Correct Answer: Isosorbide mononitrate

      Explanation:

      If a patient with symptomatic stable angina is already on a calcium channel blocker but cannot take a beta-blocker due to a contraindication, the next step in treatment should involve long-acting nitrates, ivabradine, nicorandil, or ranolazine. This scenario involves a 64-year-old man who experiences recurring chest pain during physical activity, which is likely due to poorly controlled stable angina. Although calcium channel blockers and beta-blockers are typically the first-line treatment for stable angina, the patient’s history of asthma makes beta-blockers unsuitable. As the initial treatment has not been effective, the patient should try the next line of therapy. Atenolol, bisoprolol, and diltiazem are not appropriate options for this patient due to their potential risks and lack of effectiveness in this case.

      Angina pectoris is a condition that can be managed through various methods, including lifestyle changes, medication, percutaneous coronary intervention, and surgery. In 2011, NICE released guidelines for the management of stable angina. Medication is an important aspect of treatment, and all patients should receive aspirin and a statin unless there are contraindications. Sublingual glyceryl trinitrate can be used to abort angina attacks. The first-line medication should be either a beta-blocker or a calcium channel blocker, depending on the patient’s comorbidities, contraindications, and preferences. If a calcium channel blocker is used as monotherapy, a rate-limiting one such as verapamil or diltiazem should be used. If used in combination with a beta-blocker, a longer-acting dihydropyridine calcium channel blocker should be used. Beta-blockers should not be prescribed concurrently with verapamil due to the risk of complete heart block. If the initial treatment is not effective, medication should be increased to the maximum tolerated dose. If a patient is still symptomatic after monotherapy with a beta-blocker, a calcium channel blocker can be added, and vice versa. If a patient cannot tolerate the addition of a calcium channel blocker or a beta-blocker, other drugs such as long-acting nitrates, ivabradine, nicorandil, or ranolazine can be considered. Nitrate tolerance is a common issue, and patients who take standard-release isosorbide mononitrate should use an asymmetric dosing interval to maintain a daily nitrate-free time of 10-14 hours to minimize the development of nitrate tolerance. This effect is not seen in patients who take once-daily modified-release isosorbide mononitrate. If a patient is taking both a beta-blocker and a calcium-channel blocker, a third drug should only be added while awaiting assessment for PCI or CABG.

    • This question is part of the following fields:

      • Cardiovascular
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  • Question 85 - A 29-year-old male patient informs you that he has Long QT syndrome and...

    Correct

    • A 29-year-old male patient informs you that he has Long QT syndrome and you are contemplating prescribing an antibiotic. Which antibiotic should you avoid prescribing to him?

      Your Answer: Erythromycin

      Explanation:

      A prolonged QT interval may be caused by Erythromycin.

      Understanding Long QT Syndrome

      Long QT syndrome (LQTS) is a genetic condition that causes delayed repolarization of the ventricles, which can lead to ventricular tachycardia and sudden death. The most common types of LQTS are caused by defects in the alpha subunit of the slow delayed rectifier potassium channel. A normal corrected QT interval is less than 430 ms in males and 450 ms in females.

      There are various causes of a prolonged QT interval, including congenital factors, drugs, and other medical conditions. Some drugs that can prolong the QT interval include amiodarone, tricyclic antidepressants, and selective serotonin reuptake inhibitors. Electrolyte imbalances, acute myocardial infarction, and subarachnoid hemorrhage can also cause a prolonged QT interval.

      LQTS may be picked up on routine ECG or following family screening. The symptoms and events associated with LQTS can vary depending on the type of LQTS. Long QT1 is usually associated with exertional syncope, while Long QT2 is often associated with syncope following emotional stress or exercise. Long QT3 events often occur at night or at rest.

      Management of LQTS involves avoiding drugs that prolong the QT interval and other precipitants if appropriate. Beta-blockers may be used, and in high-risk cases, implantable cardioverter defibrillators may be necessary. It is important to recognize and manage LQTS to prevent sudden cardiac death.

    • This question is part of the following fields:

      • Cardiovascular
      8.4
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  • Question 86 - What is the primary mode of operation of simvastatin in elderly patients? ...

    Correct

    • What is the primary mode of operation of simvastatin in elderly patients?

      Your Answer: Decreases intrinsic cholesterol synthesis

      Explanation:

      The rate-limiting enzyme in hepatic cholesterol synthesis, HMG-CoA reductase, is inhibited by statins.

      Statins are drugs that inhibit the action of an enzyme called HMG-CoA reductase, which is responsible for producing cholesterol in the liver. However, they can cause some adverse effects such as myopathy, which includes muscle pain, weakness, and damage, and liver impairment. Myopathy is more common in lipophilic statins than in hydrophilic ones. Statins may also increase the risk of intracerebral hemorrhage in patients who have had a stroke before. Therefore, they should be avoided in these patients. Statins should not be taken during pregnancy and should be stopped if the patient is taking macrolides.

      Statins are recommended for people with established cardiovascular disease, those with a 10-year cardiovascular risk of 10% or more, and patients with type 2 diabetes mellitus. Patients with type 1 diabetes mellitus who were diagnosed more than 10 years ago, are over 40 years old, or have established nephropathy should also take statins. It is recommended to take statins at night as this is when cholesterol synthesis takes place. Atorvastatin 20mg is recommended for primary prevention, and the dose should be increased if non-HDL has not reduced for 40% or more. Atorvastatin 80 mg is recommended for secondary prevention. The graphic shows the different types of statins available.

    • This question is part of the following fields:

      • Cardiovascular
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  • Question 87 - A 45-year-old woman is admitted with chronic congestive heart failure.

    Based on this...

    Correct

    • A 45-year-old woman is admitted with chronic congestive heart failure.

      Based on this history, what is the most important factor to consider when prescribing medication for this patient?

      Your Answer: Administration of a β-blocker reduces mortality

      Explanation:

      Treatment Options for Heart Failure: A Summary of Medications and Their Effects

      Heart failure is a serious condition that requires careful management to improve symptoms and reduce mortality rates. Two medications that have been found to be effective in reducing mortality are β-blockers and ACE inhibitors. These medications work by reducing afterload and should be offered as first-line treatment according to NICE guidelines. Loop diuretics, on the other hand, have no mortality benefit but can provide symptomatic relief. Digoxin, while effective in providing symptomatic relief, has been found to increase mortality rates and should be used with caution. Spironolactone, however, has been shown to greatly reduce mortality and sudden cardiac death rates and should be added to the treatment. Finally, while angiotensin II receptor antagonists can be used in patients who are intolerant of ACE inhibitors or added to ACE inhibitors and β-blockers if patients remain symptomatic, ACE inhibitors have been found to result in better prognosis. It is important to carefully consider the benefits and risks of each medication when treating patients with heart failure.

    • This question is part of the following fields:

      • Cardiovascular
      22.5
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  • Question 88 - An 80-year-old woman is brought to the Emergency Department by her family. She...

    Correct

    • An 80-year-old woman is brought to the Emergency Department by her family. She has been experiencing increasing shortness of breath and low energy levels for the past 6 weeks. Upon arrival, an ECG reveals 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 is recommended for controlling her heart rate?

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

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

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

    • This question is part of the following fields:

      • Cardiovascular
      25.9
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  • Question 89 - A 55-year-old woman presents to the Emergency Department with sudden-onset shortness of breath....

    Incorrect

    • A 55-year-old woman presents to the Emergency Department with sudden-onset shortness of breath. She states that this occurred while walking up a flight of stairs and stopped once she sat down. The patient states that over the past few months she has been progressively unable to climb stairs due to shortness of breath and occasional central chest heaviness which occur when she starts climbing. She has a past medical history of diabetes and smokes around 20 cigarettes daily.
      Her parameters are stable, with oxygen saturations of 97%, blood pressure of 140/90 mmHg and heart rate of 90 bpm. A chest X-ray is done which comes back as normal.
      What is the most likely diagnosis?
      Select the SINGLE most likely diagnosis from the list below.
      Select ONE option only

      Your Answer: Unstable angina

      Correct Answer: Angina pectoris

      Explanation:

      Differential Diagnosis for Chest Pain: Angina Pectoris, Anxiety Attack, COPD Exacerbation, Pneumothorax, and Unstable Angina

      Chest pain can be a symptom of various medical conditions, and it is crucial to differentiate between them to provide appropriate treatment. In this case, the patient’s symptoms suggest angina pectoris, which is characterized by constricting discomfort in the chest, neck, shoulders, jaw, or arms, triggered by physical exertion and relieved by rest or glyceryl trinitrate (GTN). However, diabetic patients may present with dyspnea instead of typical anginal pain. The patient’s cardiovascular risk factors, including diabetes, smoking, and hypertension, further support the diagnosis of angina.

      Anxiety attacks can also cause chest pain, along with palpitations, nausea, vomiting, sweating, insomnia, flushing, tremors, and urinary frequency. Therefore, anxiety should be considered as a possible diagnosis after ruling out life-threatening conditions such as ischemic heart disease.

      Exacerbation of chronic obstructive pulmonary disease (COPD) is another potential cause of chest pain, especially in smokers. However, the absence of a known COPD diagnosis and normal oxygen saturation levels make this diagnosis less likely in this case.

      Pneumothorax, a collapsed lung, can also cause chest pain, but a normal chest X-ray makes this diagnosis unlikely.

      Finally, unstable angina is a severe form of angina that can occur unexpectedly and at rest, lasting longer than stable angina and not relieved by rest. It requires emergency treatment as it can quickly progress to a heart attack. However, in this case, the patient’s symptoms occur during exercise and resolve with rest, suggesting stable angina rather than unstable angina.

      In conclusion, the differential diagnosis for chest pain includes angina pectoris, anxiety attack, COPD exacerbation, pneumothorax, and unstable angina. A thorough evaluation of the patient’s medical history, risk factors, and symptoms is necessary to determine the underlying cause and provide appropriate treatment.

    • This question is part of the following fields:

      • Cardiovascular
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  • Question 90 - A 55-year-old man with NYHA class III heart failure is currently on furosemide...

    Correct

    • A 55-year-old man with NYHA class III heart failure is currently on furosemide and ramipril. Which beta-blocker would be the most appropriate to add for improving his long-term prognosis?

      Your Answer: Bisoprolol

      Explanation:

      The use of carvedilol and bisoprolol has been proven to decrease mortality in stable heart failure patients, while there is no evidence to support the use of other beta-blockers.

      Drug Management for Chronic Heart Failure: NICE Guidelines

      Chronic heart failure is a serious condition that requires proper management to improve patient outcomes. In 2018, the National Institute for Health and Care Excellence (NICE) updated their guidelines on drug management for chronic heart failure. The guidelines recommend first-line therapy with both an ACE-inhibitor and a beta-blocker, with clinical judgement used to determine which one to start first. Second-line therapy involves the use of aldosterone antagonists, which should be monitored for hyperkalaemia. SGLT-2 inhibitors are also increasingly being used to manage heart failure with a reduced ejection fraction. Third-line therapy should be initiated by a specialist and may include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin, or cardiac resynchronisation therapy. Other treatments such as annual influenza and one-off pneumococcal vaccines are also recommended.

      Overall, the NICE guidelines provide a comprehensive approach to drug management for chronic heart failure. It is important to note that loop diuretics have not been shown to reduce mortality in the long-term, and that ACE-inhibitors and beta-blockers have no effect on mortality in heart failure with preserved ejection fraction. Healthcare professionals should carefully consider the patient’s individual needs and circumstances when determining the appropriate drug therapy for chronic heart failure.

    • This question is part of the following fields:

      • Cardiovascular
      15.3
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  • Question 91 - A 26-year-old woman comes in for her routine medical check-up before starting her...

    Correct

    • A 26-year-old woman comes in for her routine medical check-up before starting her new job as a soccer player. She reports feeling healthy and has no notable medical history in her family.

      During the physical examination, her lungs sound clear and her heart has a normal rhythm. Her pulse rate is 62 beats per minute. However, her ECG reveals sinus rhythm with a prolonged PR interval of 215ms.

      What is the appropriate course of action for managing her ECG results?

      Your Answer: No intervention needed

      Explanation:

      First-degree heart block is a common occurrence in athletes and does not require any intervention. This patient’s ECG shows a prolonged PR interval, which is the defining characteristic of first-degree heart block. As it is a normal variant, there is no need for any referral or further investigations. The patient can continue to play football without any concerns.

      Normal Variants in Athlete ECGs

      Athletes may exhibit certain ECG changes that are considered normal variants. These include sinus bradycardia, junctional rhythm, first degree heart block, and Mobitz type 1 (Wenckebach phenomenon). Sinus bradycardia refers to a slower than normal heart rate originating from the sinus node, which is the natural pacemaker of the heart. Junctional rhythm occurs when the heart’s electrical impulses originate from the junction between the atria and ventricles, rather than the sinus node. First degree heart block is a delay in the electrical conduction between the atria and ventricles, resulting in a prolonged PR interval on the ECG. Mobitz type 1, also known as Wenckebach phenomenon, is a type of heart block where there is a progressive lengthening of the PR interval until a beat is dropped. These ECG changes are considered normal in athletes and do not necessarily indicate any underlying cardiac pathology.

    • This question is part of the following fields:

      • Cardiovascular
      33
      Seconds
  • Question 92 - You are requested to evaluate a 65-year-old woman who has been admitted to...

    Correct

    • You are requested to evaluate a 65-year-old woman who has been admitted to your ward with a lower respiratory tract infection. She has a medical history of hypertension and gout and is currently taking amlodipine 10mg once daily and allopurinol 100mg once daily. You observe that her blood pressure has been consistently high over the past three days, with readings of 149/76 mmHg, 158/88 mmHg, and 150/82 mmHg. Which antihypertensive medication would be the most suitable to initiate?

      Your Answer: Lisinopril

      Explanation:

      For a patient with poorly controlled hypertension who is already taking a calcium channel blocker, the addition of an ACE inhibitor, angiotensin receptor blocker, or thiazide-like diuretic is recommended. In this case, since the patient’s hypertension remains uncontrolled, it is appropriate to start them on an ACE inhibitor or angiotensin receptor blocker, such as lisinopril. Atenolol would be a suitable option if the patient was already taking a calcium channel blocker, ACE inhibitor/ARB, and thiazide-like diuretic with a potassium level above 4.5 mmol/L. However, since the patient has a history of gout, thiazide-like diuretics like bendroflumethiazide and indapamide should be avoided as they can exacerbate gout symptoms.

      NICE Guidelines for Managing Hypertension

      Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of a calcium channel blocker or thiazide-like diuretic in addition to an ACE inhibitor or angiotensin receptor blocker.

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

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

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

    • This question is part of the following fields:

      • Cardiovascular
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  • Question 93 - A 45-year-old woman is recuperating in the hospital after a coronary angiogram for...

    Correct

    • A 45-year-old woman is recuperating in the hospital after a coronary angiogram for unstable angina. Two days after the procedure, she reports experiencing intense pain in her left foot. Upon examination, her left lower limb peripheral pulses are normal. There is tissue loss on the medial three toes on the left foot and an area of livedo reticularis on the same foot.
      What is the most probable diagnosis?

      Your Answer: Cholesterol embolisation

      Explanation:

      Differentiating Vascular Conditions: Causes and Symptoms

      Cholesterol embolisation occurs when cholesterol crystals from a ruptured atherosclerotic plaque block small or medium arteries, often following an intervention like coronary angiography. This results in microvascular ischemia, which typically does not affect blood pressure or larger vessels, explaining the normal peripheral pulses in affected patients. Livedo reticularis, a purplish discoloration, may also occur due to microvascular ischemia.

      Arterial thromboembolism is a common condition, especially in patients with established cardiovascular disease or risk factors like hypertension, hyperlipidemia, and smoking. It tends to affect larger vessels than cholesterol embolism, leading to the absence of peripheral pulses and gangrenous toes.

      Buerger’s disease, also known as thromboangiitis obliterans, is a vasculitis that mainly affects young men who smoke. It presents with claudication of the arms or legs, with or without ulcers or gangrene. However, the acute onset of symptoms following an intervention makes cholesterol embolism a more likely diagnosis.

      Deep vein thrombosis typically presents with a swollen, painful calf and does not display signs of arterial insufficiency like gangrene and livedo reticularis.

      Takayasu’s arteritis is a rare form of large vessel vasculitis that mainly affects the aorta. It is more common in women and tends to present below the age of 30 years old with pulseless arms. However, this patient’s history is not typical for Takayasu’s arteritis.

    • This question is part of the following fields:

      • Cardiovascular
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  • Question 94 - A 56-year-old man complains of fatigue. During the physical examination, a soft diastolic...

    Correct

    • A 56-year-old man complains of fatigue. During the physical examination, a soft diastolic murmur is detected, which is most audible in the second intercostal space on the right. His blood pressure is measured at 162/65 mmHg. What is the probable reason for the murmur?

      Your Answer: Aortic regurgitation

      Explanation:

      The patient exhibits a diastolic murmur that is most pronounced over the aortic valve, along with a wide pulse pressure, indicating a diagnosis of aortic regurgitation. Aortic stenosis, on the other hand, would manifest as a systolic murmur with a narrow pulse pressure. Meanwhile, mitral regurgitation would present as a systolic murmur that is most audible over the mitral valve, while mitral stenosis would produce a diastolic murmur that is loudest over the mitral valve and would not result in a wide pulse pressure.

      Aortic regurgitation is a condition where the aortic valve of the heart leaks, causing blood to flow in the opposite direction during ventricular diastole. This can be caused by disease of the aortic valve or by distortion or dilation of the aortic root and ascending aorta. In the developing world, rheumatic fever is the most common cause of AR, while in developed countries, calcific valve disease and connective tissue diseases like rheumatoid arthritis and SLE are more common causes. Symptoms of AR include an early diastolic murmur, collapsing pulse, wide pulse pressure, Quincke’s sign, and De Musset’s sign. Echocardiography is used to investigate suspected AR. Management includes medical management of any associated heart failure and surgery for symptomatic patients with severe AR or asymptomatic patients with severe AR who have LV systolic dysfunction.

    • This question is part of the following fields:

      • Cardiovascular
      24.8
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  • Question 95 - A 65-year-old man presents with palpitations and is found to have a regular,...

    Incorrect

    • A 65-year-old man presents with palpitations and is found to have a regular, monomorphic, broad complex tachycardia on cardiac monitoring. He has a history of type 2 diabetes mellitus and has undergone percutaneous coronary intervention for his left anterior descending, right coronary, and circumflex arteries. Physical examination is unremarkable except for tachycardia, and there are no signs of myocardial ischemia on a 12-lead electrocardiogram. Which of the following management options should be avoided in this case?

      Your Answer: Adenosine

      Correct Answer: Verapamil

      Explanation:

      Verapamil is contraindicated in ventricular tachycardia, which is the most probable diagnosis.

      Managing Ventricular Tachycardia

      Ventricular tachycardia is a type of rapid heartbeat that originates in the ventricles of the heart. In a peri-arrest situation, it is assumed to be ventricular in origin. If the patient shows adverse signs such as low blood pressure, chest pain, heart failure, or syncope, immediate cardioversion is necessary. However, in the absence of such signs, antiarrhythmic drugs may be used. If drug therapy fails, electrical cardioversion may be needed with synchronised DC shocks.

      There are several drugs that can be used to manage ventricular tachycardia, including amiodarone, lidocaine, and procainamide. Amiodarone is ideally administered through a central line, while lidocaine should be used with caution in severe left ventricular impairment. Verapamil should not be used in VT. If drug therapy fails, an electrophysiological study (EPS) may be conducted, or an implantable cardioverter-defibrillator (ICD) may be implanted. The ICD is particularly indicated in patients with significantly impaired LV function.

    • This question is part of the following fields:

      • Cardiovascular
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  • Question 96 - A 32-year-old woman attends her booking appointment with the community midwife. She is...

    Correct

    • A 32-year-old woman attends her booking appointment with the community midwife. She is at 14 weeks gestation in her second pregnancy. She has no underlying medical conditions.
      Which of the following haemodynamic changes is most likely to present in this patient?

      Your Answer: A 10 mmHg drop in diastolic blood pressure (BP) during the second trimester

      Explanation:

      Physiological Changes in Cardiovascular System During Pregnancy

      During pregnancy, the cardiovascular system undergoes significant changes to accommodate the growing fetus. These changes include a drop in diastolic blood pressure by 10 mmHg during the second trimester, circulating blood volume increases by approximately 50%, leading to a dilutional ‘physiological anaemia’ and cardiac output increases most sharply throughout the first trimester.

      During pregnancy, heart rate progressively increases until reaching a peak in the third trimester. The overall change in heart rate represents approximately a 20–25% increase from baseline. However, a grade 2/6 diastolic murmur at the mitral area and pulsus alternans are not typical findings in a healthy pregnancy. It is important for healthcare providers to be aware of these physiological changes to properly monitor and manage the health of pregnant individuals.

    • This question is part of the following fields:

      • Cardiovascular
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  • Question 97 - A 70-year-old man presents to the GP for a blood pressure review after...

    Correct

    • A 70-year-old man presents to the GP for a blood pressure review after a clinic reading of 154/100 mmHg. He has a medical history of type 2 diabetes and COPD, which are managed with inhalers. His home blood pressure readings over the past week have averaged at 140/96 mmHg. What is the initial intervention that should be considered?

      Your Answer: Ramipril

      Explanation:

      Regardless of age, ACE inhibitors/A2RBs are the first-line treatment for hypertension in diabetics.

      Blood Pressure Management in Diabetes Mellitus

      Patients with diabetes mellitus have traditionally been managed with lower blood pressure targets to reduce their overall cardiovascular risk. However, a 2013 Cochrane review found that there was little difference in outcomes between patients who had tight blood pressure control (targets < 130/85 mmHg) and those with more relaxed control (< 140-160/90-100 mmHg), except for a slightly reduced rate of stroke in the former group. As a result, NICE recommends a blood pressure target of < 140/90 mmHg for type 2 diabetics, the same as for patients without diabetes. For patients with type 1 diabetes, NICE recommends a blood pressure target of 135/85 mmHg unless they have albuminuria or two or more features of metabolic syndrome, in which case the target should be 130/80 mmHg. ACE inhibitors or angiotensin-II receptor antagonists (A2RBs) are the first-line antihypertensive regardless of age, as they have a renoprotective effect in diabetes. A2RBs are preferred for black African or African-Caribbean diabetic patients. Further management then follows that of non-diabetic patients. It is important to note that autonomic neuropathy may result in more postural symptoms in patients taking antihypertensive therapy. Therefore, the routine use of beta-blockers in uncomplicated hypertension should be avoided, particularly when given in combination with thiazides, as they may cause insulin resistance, impair insulin secretion, and alter the autonomic response to hypoglycemia.

    • This question is part of the following fields:

      • Cardiovascular
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  • Question 98 - A 45-year-old woman presents to the Emergency Department with a 2-day history of...

    Incorrect

    • A 45-year-old woman presents to the Emergency Department with a 2-day history of pleuritic chest pain. She states that this started in the evening and has gotten worse since then. The pain is central and seems to improve when she leans forward. She has a past medical history of hypertension.
      An electrocardiogram (ECG) is performed which shows widespread concave ST-segment elevation and PR interval depression. Extensive investigations reveal no underlying cause.
      Given the likely diagnosis, which of the following is the best treatment option?
      Select the SINGLE best treatment option from the list below.

      Your Answer: Colchicine for three months

      Correct Answer: NSAIDs until symptomatic resolution along with colchicine for three months

      Explanation:

      Treatment Options for Acute Pericarditis

      Acute pericarditis requires prompt treatment to prevent complications such as recurrent pericarditis, pericardial effusions, cardiac tamponade, and chronic constrictive pericarditis. The initial treatment for idiopathic or viral pericarditis involves high-dose non-steroidal anti-inflammatory drugs (NSAIDs) or aspirin in combination with colchicine. The duration of NSAID or aspirin treatment depends on symptom resolution and normalization of C-reactive protein (CRP), while colchicine treatment is continued for three months using a low, weight-adjusted dose. Strenuous physical activity should be restricted until symptom resolution and normalization of inflammatory markers, and gastroprotection with a proton-pump inhibitor is recommended.

      If NSAIDs and colchicine are contraindicated, low-dose corticosteroids are the next step in the treatment algorithm, after exclusion of infectious causes. However, when the cause of the pericarditis is known, it must be treated first before starting anti-inflammatory treatment.

      Managing Acute Pericarditis: Treatment Options and Considerations

    • This question is part of the following fields:

      • Cardiovascular
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  • Question 99 - A 55-year-old caucasian man comes in for his annual hypertension check-up. He has...

    Correct

    • A 55-year-old caucasian man comes in for his annual hypertension check-up. He has already completed a blood pressure diary at home, which shows an average daytime reading of 160/100 mmHg. During his visit today, his blood pressure is measured at 174/110 mmHg. He is currently taking ramipril 10mg daily and is fully compliant with his medication.

      In addition to hypertension, he has a history of recurrent gout and takes allopurinol for it. He has no other medical issues. Since his hypertension diagnosis, he has quit smoking and has taken steps to improve his lifestyle.

      What would be the most appropriate course of action?

      Your Answer: Add nifedipine

      Explanation:

      If a patient with hypertension is already on an ACE inhibitor and has a history of gout, it would be more appropriate to prescribe a calcium channel blocker rather than a thiazide as the next step in treatment. Nifedipine is the recommended choice for this patient. The target blood pressure for adults under 80 years old with hypertension is below 140/90 mmHg. If a single medication is not controlling the patient’s blood pressure, a second agent should be considered after checking treatment adherence. For a Caucasian man under 55 years old, the first step in treatment is an ACE inhibitor or an ARB. The second step is the addition of a CCB or thiazide-like diuretic, depending on clinical factors. However, in this case, the patient’s history of gout makes nifedipine a more appropriate choice than bendroflumethiazide. Doxazosin is not recommended for stage 2 hypertension, and losartan should not be used together with an ACE inhibitor. Lifestyle changes and repeat blood pressure in 3 months are not sufficient at this stage, as a single medication may not be enough to control hypertension.

      NICE Guidelines for Managing Hypertension

      Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of a calcium channel blocker or thiazide-like diuretic in addition to an ACE inhibitor or angiotensin receptor blocker.

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

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

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

    • This question is part of the following fields:

      • Cardiovascular
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  • Question 100 - A 63-year-old woman presents for follow-up. She completed a 6 month course of...

    Correct

    • A 63-year-old woman presents for follow-up. She completed a 6 month course of warfarin a year ago after being diagnosed with an unprovoked, proximal deep vein thrombosis. Over the past few weeks, she has been experiencing a sensation of heaviness and aching in the same leg, accompanied by itching and some swelling that subsides each night. Her medical history includes osteoarthritis and type 2 diabetes mellitus. On examination, there are prominent varicose veins on the affected leg, and the skin above the medial malleolus is discolored. The calves have no difference in circumference. Her vital signs are as follows: temperature 36.9ºC, pulse 78/min, and blood pressure 108/82 mmHg. What is the most probable diagnosis?

      Your Answer: Post-thrombotic syndrome

      Explanation:

      The symptoms of pruritus and pain that gradually worsen, along with the results of the examination, indicate a high likelihood of post-thrombotic syndrome.

      Post-Thrombotic Syndrome: A Complication of Deep Vein Thrombosis

      Post-thrombotic syndrome is a clinical syndrome that may develop following a deep vein thrombosis (DVT). It is caused by venous outflow obstruction and venous insufficiency, which leads to chronic venous hypertension. Patients with post-thrombotic syndrome may experience painful, heavy calves, pruritus, swelling, varicose veins, and venous ulceration.

      In the past, compression stockings were offered to patients with DVT to reduce the risk of post-thrombotic syndrome. However, current recommendations state that elastic graduated compression stockings should not be used to prevent post-thrombotic syndrome or VTE recurrence after a proximal DVT. This recommendation does not cover the use of elastic stockings for the management of leg symptoms after DVT.

      Once post-thrombotic syndrome has developed, compression stockings are a recommended treatment. Other recommendations include keeping the leg elevated. It is important for healthcare providers to recognize the potential complications of DVT and to provide appropriate management to prevent the development of post-thrombotic syndrome.

    • This question is part of the following fields:

      • Cardiovascular
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  • Question 101 - A 35-year-old homeless man is brought to the emergency department after being found...

    Correct

    • A 35-year-old homeless man is brought to the emergency department after being found unresponsive in a local park. Upon admission, his temperature is 30.2 ºC and an ECG reveals a broad complex polymorphic tachycardia. The patient is diagnosed with torsades de pointes. What is the most suitable course of treatment?

      Your Answer: Magnesium sulphate

      Explanation:

      Torsades de pointes can be treated with IV magnesium sulfate.

      Torsades de Pointes: A Life-Threatening Condition

      Torsades de pointes is a type of ventricular tachycardia that is associated with a prolonged QT interval. This condition can lead to ventricular fibrillation, which can cause sudden death. There are several causes of a prolonged QT interval, including congenital conditions such as Jervell-Lange-Nielsen syndrome and Romano-Ward syndrome, as well as certain medications like antiarrhythmics, tricyclic antidepressants, and antipsychotics. Other causes include electrolyte imbalances, myocarditis, hypothermia, and subarachnoid hemorrhage.

      The management of torsades de pointes involves the administration of intravenous magnesium sulfate. This can help to stabilize the heart rhythm and prevent further complications.

    • This question is part of the following fields:

      • Cardiovascular
      12.6
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  • Question 102 - A 28-year-old professional basketball player presents with complaints of feeling lightheaded during exercise....

    Correct

    • A 28-year-old professional basketball player presents with complaints of feeling lightheaded during exercise. Upon physical examination, a laterally displaced apical impulse is noted. Auscultation reveals a 2/6 mid-systolic murmur in the mitral area that increases upon sudden standing. The ECG shows LVH and Q waves in V1–4 leads.

      What is the most probable diagnosis?

      Your Answer: Hypertrophic cardiomyopathy

      Explanation:

      Differential Diagnosis for a Patient with Dyspnoea and a Murmur: Hypertrophic Cardiomyopathy

      Hypertrophic cardiomyopathy is a condition that can lead to sudden death in young athletes and is characterized by dyspnoea, LVH, and a loud S4. The systolic murmur associated with hypertrophic cardiomyopathy does not radiate to the carotids and can be differentiated from aortic stenosis, which causes a crescendo-decrescendo murmur that does radiate to the carotids. Young-onset hypertension is unlikely to cause a murmur, and acute myocardial infarction would show ST elevation or depression on ECG, but not LVH. Atrial septal defect is usually picked up in newborn checks and presents with a brief murmur in early systole and early diastole, while hypertrophic cardiomyopathy presents with a double or triple apical impulse and a characteristic jerky carotid pulse. It is important to recognize the symptoms and signs of hypertrophic cardiomyopathy to prevent sudden death in young athletes.

    • This question is part of the following fields:

      • Cardiovascular
      18.5
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  • Question 103 - As a physician on the night shift cardiac arrest team, you receive an...

    Incorrect

    • As a physician on the night shift cardiac arrest team, you receive an emergency page requesting immediate assistance on the geriatric ward. Upon arrival, you discover the nursing staff performing chest compressions on an unresponsive patient with no carotid pulse. You instruct them to continue compressions while you apply defibrillator pads to the patient's chest. After a brief pause in compressions, the defibrillator monitor displays a monomorphic, broad complex tachycardia. What is the next best course of action?

      Your Answer: Immediately give 3 back-to-back defibrillator shocks followed by CPR

      Correct Answer: Immediately give 1 defibrillator shock followed by CPR

      Explanation:

      When pulseless ventricular tachycardia (VT) is identified, the immediate and correct treatment is a single defibrillator shock followed by 2 minutes of CPR. This is in contrast to using intravenous adenosine or amiodarone, which are not appropriate in this scenario. The Resuscitation Council (UK) guidelines now recommend a single shock for ventricular fibrillation (VF) or pulseless VT. Administering 3 back-to-back shocks followed by 1 minute of CPR is part of the Advanced Life Support (ALS) algorithm, but it is not the most appropriate next step in management for a delayed recognition of rhythm like in the above case. In contrast, continued CPR with 30 chest compressions to 2 breaths is appropriate in a basic life support scenario where a defibrillator is not yet available.

      The 2015 Resus Council guidelines for adult advanced life support outline the steps to be taken when dealing with patients with shockable and non-shockable rhythms. For both types of patients, chest compressions are a crucial part of the process, with a ratio of 30 compressions to 2 ventilations. Defibrillation is recommended for shockable rhythms, with a single shock for VF/pulseless VT followed by 2 minutes of CPR. Adrenaline and amiodarone are the drugs of choice for non-shockable rhythms, with adrenaline given as soon as possible and amiodarone administered after 3 shocks for VF/pulseless VT. Thrombolytic drugs should be considered if a pulmonary embolus is suspected. Atropine is no longer recommended for routine use in asystole or PEA. Oxygen should be titrated to achieve saturations of 94-98% following successful resuscitation. The Hs and Ts should be considered as potential reversible causes of cardiac arrest.

    • This question is part of the following fields:

      • Cardiovascular
      55
      Seconds
  • Question 104 - A 55-year-old woman with a history of diabetes, obesity, and smoking developed sudden...

    Incorrect

    • A 55-year-old woman with a history of diabetes, obesity, and smoking developed sudden pain in her left foot with a dusky colour change. On examination, in the Emergency Department, she had a cold, blue, painful foot with an absent dorsalis pedis and posterior tibial pulse.
      Which of the following will be the most appropriate investigation for this patient?

      Your Answer: Ankle–brachial pressure index (ABPI)

      Correct Answer: Lower limb angiography

      Explanation:

      Diagnostic Tests for Lower Limb Ischaemia

      Lower limb ischaemia is a medical emergency that requires prompt diagnosis and treatment. Several diagnostic tests can be used to determine the cause and severity of the condition. Here are some of the most common tests:

      1. Lower limb angiography: This test can identify the site of arterial occlusion and help plan the appropriate treatment, such as embolectomy or fasciotomy.
      2. Focused assessment with sonography for trauma (FAST) scan of the abdomen: This test is useful in cases of trauma or suspected abdominal aortic aneurysm rupture.
      3. Ankle-brachial pressure index (ABPI): This quick and easy test can provide an early indication of the severity of ischaemia. A value of 0.9-1.2 is considered normal, while values below 0.3 indicate critical ischaemia.
      4. Echocardiogram: This test can rule out a cardiac source of embolisation, but lower limb angiography is the priority in cases of acute ischaemia.
      5. Lower limb Doppler: This test can be used to assess arterial or venous flow, depending on the suspected cause of ischaemia.

      In summary, a combination of these diagnostic tests can help diagnose and treat lower limb ischaemia effectively.

    • This question is part of the following fields:

      • Cardiovascular
      51
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  • Question 105 - A 58-year-old woman comes to the Emergency Department complaining of a painful left...

    Correct

    • A 58-year-old woman comes to the Emergency Department complaining of a painful left leg that has been getting worse for several hours. She has no other symptoms and has a medical history of asthma, hypertension, and a laparoscopic cholecystectomy 8 weeks ago.

      During the examination, the left calf diameter is approximately 4 cm larger than the right calf, but there is no oedema.

      What would be the most suitable initial investigation?

      Your Answer: Proximal leg vein ultrasound

      Explanation:

      If the Wells score for a suspected deep vein thrombosis (DVT) is 2 or higher, a proximal leg vein ultrasound scan should be arranged within 4 hours. In this case, the patient’s Wells score is 2 due to recent major surgery within 12 weeks and a calf swelling at least 3 cm larger than the asymptomatic side. It is important to note that a CT angiogram of the leg is not appropriate for diagnosing DVT, and ultrasound is the preferred imaging modality. A CT pulmonary angiogram would only be necessary if the patient had symptoms suggestive of pulmonary embolism. A chest X-ray is not relevant in this scenario. If ultrasound is not possible within 4 hours, a D-dimer test could be performed and interim therapeutic anticoagulation given, but the initial choice is to perform an ultrasound scan as soon as possible.

      NICE updated their guidelines on the investigation and management of venous thromboembolism (VTE) in 2020. The use of direct oral anticoagulants (DOACs) is recommended as first-line treatment for most people with VTE, including as interim anticoagulants before a definite diagnosis is made. Routine cancer screening is no longer recommended following a VTE diagnosis. The cornerstone of VTE management is anticoagulant therapy, with DOACs being the preferred choice. All patients should have anticoagulation for at least 3 months, with the length of anticoagulation being determined by whether the VTE was provoked or unprovoked.

    • This question is part of the following fields:

      • Cardiovascular
      19.3