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Question 1
Correct
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A 65-year-old man with known congestive cardiac failure presents to his General Practitioner for his annual review. He reports that his heart failure symptoms have been stable in recent months. On examination his heart rate is 68 bpm but is noted to be irregularly irregular, blood pressure is 136/84 mmHg, respiratory rate 18 breaths per minute and oxygen saturations 95% in air. An electrocardiogram (ECG) confirms atrial fibrillation (AF) with a stable ventricular rate of 72 bpm.
Which single medication from the following list would be most beneficial from the point of view of this patient’s atrial fibrillation?
Your Answer: Warfarin
Explanation:Treatment Options for Atrial Fibrillation: Anticoagulation with Warfarin as Initial Therapy
Atrial fibrillation (AF) patients who are haemodynamically stable have an intermediate risk and require anticoagulation therapy. The initial treatment for such patients is anticoagulation with warfarin, which is also indicated in valvular heart disease and the elderly. Other options for anticoagulation include apixaban, dabigatran etexilate, and rivaroxaban, within their licensed indications. The decision to use anticoagulation in AF is guided by the CHA2DS2-VASc scores, which assess the risk factors for stroke. Patients with a very low risk of stroke (CHA2DS2-VASc score of 0 for men, or 1 for women) should not be offered stroke prevention therapy. Anticoagulation should be offered to people with a CHA2DS2-VASc score of 2 (1 in men) or above, taking bleeding risk into account.
While furosemide is a potential treatment for congestive cardiac failure, it is not urgently required in haemodynamically stable patients. Aspirin is no longer recommended for stroke prevention in any patient with AF. Digoxin is a potential rate-limiting medication in people with non-paroxysmal AF, but rate limitation is not the first priority in this case as the ventricular rate is normal. Sotalol, a cardioselective beta-blocker, is used in rate control for AF with a fast ventricular response, but is not required for this patient.
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This question is part of the following fields:
- Cardiovascular Health
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Question 2
Incorrect
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A 48-year-old male attends a well man clinic.
On review of his history he has a strong family history of ischaemic heart disease and is a smoker of 10 cigarettes per day and drinks approximately 20 units of alcohol per week.
On examination, he is obese with a BMI of 32 kg/m2 and has a blood pressure of 152/88 mmHg.
His investigations reveal that he has a fasting plasma glucose of 10.5 mmol/L (3.0-6.0), HbA1c of 62 mmol/mol (20-46) and his cholesterol concentration is 5.5 mmol/L (<5.2).
Which of the following would be expected to be most effective in reducing his cardiovascular (CV) risk?Your Answer: Stop smoking
Correct Answer: Weight loss with Xenical
Explanation:Managing Hypertension and Diabetes for Cardiovascular Risk Reduction
This patient is diagnosed with hypertension and diabetes, as indicated by the elevated fasting plasma glucose. While metformin, ramipril, and statins have been shown to reduce cardiovascular (CV) risk in obese diabetics and hypertensive diabetics, respectively, none of these interventions are as effective as smoking cessation in reducing CV risk. The Nurses’ Health Study provides the best evidence for the risk reduction in past and current smokers among women. However, there is less definitive evidence for men. Despite this, it is unlikely that many practitioners would consider the other interventions to be of relatively more benefit than smoking cessation. There is currently no evidence that weight loss alone reduces CV mortality, possibly due to the lack of studies conducted on this topic.
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This question is part of the following fields:
- Cardiovascular Health
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Question 3
Correct
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You assess a 52-year-old patient with hypertension who has been taking 2.5mg of ramipril for a month. He reports experiencing a persistent tickly cough that is causing him to lose sleep at night. Despite this, his blood pressure is now under control.
What recommendations would you provide to him?Your Answer: Stop the ramipril and prescribe candesartan
Explanation:When patients are unable to tolerate ACE inhibitors due to the common side effect of a dry, persistent cough, angiotensin-receptor blockers (ARBs) should be considered as an alternative. For individuals under the age of 55 who experience intolerance to ACE inhibitors, prescribing medications such as candesartan, an ARB, may be the next appropriate step.
Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of calcium channel blockers or thiazide-like diuretics in addition to ACE inhibitors or angiotensin receptor blockers.
Lifestyle changes are also important in managing hypertension. Patients should aim for a low salt diet, reduce caffeine intake, stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more, and lose weight.
Treatment for hypertension depends on the patient’s blood pressure classification. For stage 1 hypertension with ABPM/HBPM readings of 135/85 mmHg or higher, treatment is recommended for patients under 80 years old with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For stage 2 hypertension with ABPM/HBPM readings of 150/95 mmHg or higher, drug treatment is recommended regardless of age.
The first-line treatment for patients under 55 years old or with a background of type 2 diabetes mellitus is an ACE inhibitor or angiotensin receptor blocker. Calcium channel blockers are recommended for patients over 55 years old or of black African or African-Caribbean origin. If a patient is already taking an ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker or thiazide-like diuretic can be added.
If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, NICE recommends seeking expert advice or adding a fourth drug. Blood pressure targets vary depending on age, with a target of 140/90 mmHg for patients under 80 years old and 150/90 mmHg for patients over 80 years old. Direct renin inhibitors, such as Aliskiren, may be used in patients who are intolerant of other antihypertensive drugs, but their role is currently limited.
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This question is part of the following fields:
- Cardiovascular Health
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Question 4
Incorrect
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A 65-year-old Afro-Caribbean woman has a blood pressure of 150/96 mmHg on ambulatory blood pressure testing.
She has no heart murmurs and her chest is clear. Past medical history includes asthma and chronic lymphoedema of the legs.
As per the latest NICE guidance on hypertension (NG136), what would be the most suitable approach to manage her blood pressure in this situation?Your Answer:
Correct Answer: Advise lifestyle changes and repeat in one year
Explanation:NICE Guidance on Antihypertensive Treatment for People Over 55 and Black People of African or Caribbean Family Origin
According to the latest NICE guidance, people aged over 55 years and black people of African or Caribbean family origin of any age should be offered step 1 antihypertensive treatment with a CCB. If a CCB is not suitable due to oedema or intolerance, or if there is evidence of heart failure or a high risk of heart failure, a thiazide-like diuretic should be offered instead.
This guidance aims to provide effective treatment options for hypertension in these specific populations, taking into account individual circumstances and potential side effects. It is important for healthcare professionals to follow these recommendations to ensure the best possible outcomes for their patients.
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This question is part of the following fields:
- Cardiovascular Health
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Question 5
Incorrect
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A 26-year-old female comes to her GP complaining of feeling tired and experiencing episodes of dizziness. During the examination, the GP observes an absent pulse in the patient's left radial artery. The following blood test results are obtained:
- Sodium (Na+): 136 mmol/l
- Potassium (K+): 4.1 mmol/l
- Urea: 2.3 mmol/l
- Creatinine: 77 µmol/l
- Erythrocyte sedimentation rate (ESR): 66 mm/hr
Based on these findings, what is the most likely diagnosis?Your Answer:
Correct Answer: Takayasu's arteritis
Explanation:Takayasu’s arteritis is a type of vasculitis that affects the large blood vessels, often leading to blockages in the aorta. This condition is more commonly seen in young women and Asian individuals. Symptoms may include malaise, headaches, unequal blood pressure in the arms, carotid bruits, absent or weak peripheral pulses, and claudication in the limbs during physical activity. Aortic regurgitation may also occur in around 20% of cases. Renal artery stenosis is a common association with this condition. To diagnose Takayasu’s arteritis, vascular imaging of the arterial tree is necessary, which can be done through magnetic resonance angiography or CT angiography. Treatment typically involves the use of steroids.
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This question is part of the following fields:
- Cardiovascular Health
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Question 6
Incorrect
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A 50-year-old man comes in for a check-up. He is of Afro-Caribbean heritage and has been on a daily dose of amlodipine 10 mg. Upon reviewing his blood pressure readings, it has been found that he has an average of 154/93 mmHg over the past 2 months. Today, his blood pressure is at 161/96 mmHg. The patient is eager to bring his blood pressure under control. What is the most effective treatment to initiate in this scenario?
Your Answer:
Correct Answer: Add angiotensin receptor blocker
Explanation:If a black African or African-Caribbean patient with hypertension is already taking a calcium channel blocker and requires a second medication, it is recommended to add an angiotensin receptor blocker instead of an ACE inhibitor. This is because studies have shown that this class of medication is more effective in patients of this heritage. In this case, the patient would benefit from the addition of candesartan to lower their blood pressure. An alpha-blocker is not necessary at this stage, and a beta-blocker is not recommended as it is better suited for heart failure and post-myocardial infarction. Increasing the dose of amlodipine is also unlikely to be helpful as the patient is already on the maximum dose.
Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of calcium channel blockers or thiazide-like diuretics in addition to ACE inhibitors or angiotensin receptor blockers.
Lifestyle changes are also important in managing hypertension. Patients should aim for a low salt diet, reduce caffeine intake, stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more, and lose weight.
Treatment for hypertension depends on the patient’s blood pressure classification. For stage 1 hypertension with ABPM/HBPM readings of 135/85 mmHg or higher, treatment is recommended for patients under 80 years old with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For stage 2 hypertension with ABPM/HBPM readings of 150/95 mmHg or higher, drug treatment is recommended regardless of age.
The first-line treatment for patients under 55 years old or with a background of type 2 diabetes mellitus is an ACE inhibitor or angiotensin receptor blocker. Calcium channel blockers are recommended for patients over 55 years old or of black African or African-Caribbean origin. If a patient is already taking an ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker or thiazide-like diuretic can be added.
If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, NICE recommends seeking expert advice or adding a fourth drug. Blood pressure targets vary depending on age, with a target of 140/90 mmHg for patients under 80 years old and 150/90 mmHg for patients over 80 years old. Direct renin inhibitors, such as Aliskiren, may be used in patients who are intolerant of other antihypertensive drugs, but their role is currently limited.
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This question is part of the following fields:
- Cardiovascular Health
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Question 7
Incorrect
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A 50-year-old woman, who has a history of atrial fibrillation and is receiving warfarin and digoxin, tells you that she has been feeling low lately and has been self medicating with St John's wort which she bought from a health store.
Which of the following interactions can be anticipated between St John's Wort and her current medication?Your Answer:
Correct Answer: INR is likely to be reduced
Explanation:St John’s Wort and Medication Interactions
St John’s wort is a popular natural remedy for depressive symptoms. However, it is important to note that it is a liver enzyme inducer, which can lead to interactions with other medications. For example, St John’s wort may reduce the efficacy of warfarin, a blood thinner, requiring an increased dose to maintain the desired level of anticoagulation. It may also reduce the efficacy of digoxin, a medication used to treat heart failure. Therefore, it is important to discuss the use of St John’s wort with a healthcare provider before taking it in combination with other medications. By doing so, potential interactions can be identified and managed appropriately.
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This question is part of the following fields:
- Cardiovascular Health
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Question 8
Incorrect
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Which Antihypertensive medication is banned for use by professional athletes?
Your Answer:
Correct Answer: Doxazosin
Explanation:Prohibited Substances in Sports
Beta-blockers and diuretics are among the substances prohibited in certain sports. In billiards and archery, the use of beta-blockers is not allowed as they can enhance performance by reducing anxiety and tremors. On the other hand, diuretics are generally prohibited as they can be used as masking agents to hide the presence of other banned substances. It is important to note that diuretics can be found in some combination products, such as Cozaar-Comp which contains hydrochlorothiazide. Athletes should be aware of the substances they are taking and ensure that they are not violating any anti-doping regulations.
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This question is part of the following fields:
- Cardiovascular Health
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Question 9
Incorrect
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During his annual health review, a 67-year-old man with type 2 diabetes, hypercholesterolaemia, and hypertension is taking metformin, gliclazide, atorvastatin, and ramipril. His recent test results show a Na+ level of 139 mmol/L (135 - 145), K+ level of 4.1 mmol/L (3.5 - 5.0), creatinine level of 90 µmol/L (55 - 120), estimated GFR of 80 mL/min/1.73m² (>90), HbA1c level of 59 mmol/mol (<42), and urine albumin: creatinine ratio of <3 mg/mmol (<3). What is the recommended target clinic blood pressure (in mmHg)?
Your Answer:
Correct Answer:
Explanation:For patients with type 2 diabetes who do not have chronic kidney disease, the recommended blood pressure targets are the same as for patients without diabetes. This means a clinic reading of less than 140/90 mmHg and an ambulatory or home blood pressure reading of less than 135/85 mmHg if the patient is under 80 years old. It’s important to note that even if the patient’s estimated glomerular filtration rate (eGFR) is below 90, this doesn’t necessarily mean they have CKD unless there is also evidence of microalbuminuria.
NICE has updated its guidance on the management of type 2 diabetes mellitus (T2DM) in 2022 to reflect advances in drug therapy and improved evidence regarding newer therapies such as SGLT-2 inhibitors. For the average patient taking metformin for T2DM, lifestyle changes and titrating up metformin to aim for a HbA1c of 48 mmol/mol (6.5%) is recommended. A second drug should only be added if the HbA1c rises to 58 mmol/mol (7.5%). Dietary advice includes encouraging high fiber, low glycemic index sources of carbohydrates, controlling intake of saturated fats and trans fatty acids, and initial target weight loss of 5-10% in overweight individuals.
Individual HbA1c targets should be agreed upon with patients to encourage motivation, and HbA1c should be checked every 3-6 months until stable, then 6 monthly. Targets should be relaxed on a case-by-case basis, with particular consideration for older or frail adults with type 2 diabetes. Metformin remains the first-line drug of choice, and SGLT-2 inhibitors should be given in addition to metformin if the patient has a high risk of developing cardiovascular disease (CVD), established CVD, or chronic heart failure. If metformin is contraindicated, SGLT-2 monotherapy or a DPP-4 inhibitor, pioglitazone, or sulfonylurea may be used.
Further drug therapy options depend on individual clinical circumstances and patient preference. Dual therapy options include adding a DPP-4 inhibitor, pioglitazone, sulfonylurea, or SGLT-2 inhibitor (if NICE criteria are met). If a patient doesn’t achieve control on dual therapy, triple therapy options include adding a sulfonylurea or GLP-1 mimetic. GLP-1 mimetics should only be added to insulin under specialist care. Blood pressure targets are the same as for patients without type 2 diabetes, and ACE inhibitors or ARBs are first-line for hypertension. Antiplatelets should not be offered unless a patient has existing cardiovascular disease, and only patients with a 10-year cardiovascular risk > 10% should be offered a statin.
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This question is part of the following fields:
- Cardiovascular Health
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Question 10
Incorrect
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Which patient with cardiac issues would you deem suitable for air travel?
Your Answer:
Correct Answer: Patient who had an uncomplicated myocardial infarction (MI) two days ago
Explanation:Understanding Fitness to Fly Guidelines for Medical Conditions
Fitness to fly can be a complex topic, and it is important to advise patients to consult their airline for specific policies regarding their medical condition. The UK Civil Aviation Authority’s aviation health unit has produced guidelines for healthcare professionals to clarify fitness to fly for various medical conditions. These guidelines provide a concise overview of key points that are commonly encountered in general practice.
When it comes to cardiovascular contraindications for commercial airline flights, there are several factors to consider. For example, patients who have had an uncomplicated myocardial infarction within the last seven days or a coronary artery bypass graft within the last ten days are not fit to travel. However, patients who have undergone percutaneous coronary intervention/stenting may be fit to travel after a minimum of five days, but they require medical assessment. Additionally, patients with unstable angina or uncontrolled cardiac arrhythmia should not fly.
It is important to note that different sources may provide slightly different guidance on fitness to fly. However, the CAA guidelines are considered the closest to national guidance and are likely to be used in examination questions. Examining bodies may also choose answers that fall within the reference range of multiple accredited sources to avoid controversial answers. Overall, understanding fitness to fly guidelines for medical conditions is crucial for ensuring the safety and well-being of patients during air travel.
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This question is part of the following fields:
- Cardiovascular Health
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Question 11
Incorrect
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During a late-night shift at an urgent care centre, you encounter a 30-year-old woman who complains of experiencing pain and swelling in her right leg for the past three days. She denies having chest pain or difficulty breathing and is currently taking the combined oral contraceptive pill.
Upon examination, you notice that her right leg is swollen and tender to the touch. Her heart rate and pulse oximetry are both normal. After calculating a Wells deep vein thrombosis (DVT) score of 2, you advise her to visit her GP surgery the next morning for urgent blood tests, including a d-dimer, and to be monitored by the duty GP at her practice. You also instruct her to stop taking her contraceptive pill in the meantime.
What would be the most appropriate course of action to take in this situation?Your Answer:
Correct Answer: Prescribe apixaban
Explanation:If there is suspicion of a DVT and it is not possible to obtain a D-dimer or scan result within four hours, NICE recommends initiating anticoagulation treatment with a DOAC such as apixaban. Low molecular weight heparin is no longer the preferred option. Clopidogrel is not effective in treating DVT. Warfarin, which was previously used, has been largely replaced by DOACs, but may still be used in some cases with low molecular weight heparin until the INR is within target range.
Deep vein thrombosis (DVT) is a serious condition that requires prompt diagnosis and management. The National Institute for Health and Care Excellence (NICE) updated their guidelines in 2020, recommending the use of direct oral anticoagulants (DOACs) as first-line treatment for most people with VTE, including as interim anticoagulants before a definite diagnosis is made. They also recommend the use of DOACs in patients with active cancer, as opposed to low-molecular weight heparin as was previously recommended. Routine cancer screening is no longer recommended following a VTE diagnosis.
If a patient is suspected of having a DVT, a two-level DVT Wells score should be performed to assess the likelihood of the condition. If a DVT is ‘likely’ (2 points or more), a proximal leg vein ultrasound scan should be carried out within 4 hours. If the result is positive, then a diagnosis of DVT is made and anticoagulant treatment should start. If the result is negative, a D-dimer test should be arranged. If a proximal leg vein ultrasound scan cannot be carried out within 4 hours, a D-dimer test should be performed and interim therapeutic anticoagulation administered whilst waiting for the proximal leg vein ultrasound scan (which should be performed within 24 hours).
The cornerstone of VTE management is anticoagulant therapy. The big change in the 2020 guidelines was the increased use of DOACs. Apixaban or rivaroxaban (both DOACs) should be offered first-line following the diagnosis of a DVT. Instead of using low-molecular weight heparin (LMWH) until the diagnosis is confirmed, NICE now advocate using a DOAC once a diagnosis is suspected, with this continued if the diagnosis is confirmed. If neither apixaban or rivaroxaban are suitable, then either LMWH followed by dabigatran or edoxaban OR LMWH followed by a vitamin K antagonist (VKA, i.e. warfarin) can be used.
All patients should have anticoagulation for at least 3 months. Continuing anticoagulation after this period is partly determined by whether the VTE was provoked or unprovoked. If the VTE was provoked, the treatment is typically stopped after the initial 3 months (3 to 6 months for people with active cancer). If the VTE was
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This question is part of the following fields:
- Cardiovascular Health
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Question 12
Incorrect
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A patient is at highest risk of developing venous thromboembolism due to which of the following options? Please select only one.
Your Answer:
Correct Answer: Hip fracture
Explanation:Predisposing Factors for Pulmonary Embolism
Pulmonary embolism is a serious medical condition that occurs when a blood clot travels to the lungs and blocks blood flow. Certain factors can increase the risk of developing pulmonary embolism.
Strong predisposing factors, with an odds ratio greater than 10, include fractures (hip or leg), hip or knee replacement, major general surgery, major trauma, and spinal cord injury.
Moderate predisposing factors, with an odds ratio between 2 and 9, include arthroscopic knee surgery, central venous lines, chemotherapy, chronic heart or respiratory failure, hormone replacement therapy, malignancy, oral contraceptive therapy, paralytic stroke, pregnancy/postpartum, previous venous thromboembolism, and thrombophilia.
Weak predisposing factors, with an odds ratio of 2 or less, include bed rest for more than 3 days, immobility due to sitting (such as prolonged car or air travel), increasing age, laparoscopic surgery (such as cholecystectomy), obesity, pregnancy/antepartum, and varicose veins.
It is important to be aware of these predisposing factors and take appropriate measures to prevent pulmonary embolism, especially in high-risk individuals.
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This question is part of the following fields:
- Cardiovascular Health
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Question 13
Incorrect
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A 73-year-old man who underwent bioprosthetic aortic valve replacement three years ago is being evaluated. What type of antithrombotic treatment is he expected to be receiving?
Your Answer:
Correct Answer: Aspirin
Explanation:For patients with prosthetic heart valves, antithrombotic therapy varies depending on the type of valve. Bioprosthetic valves typically require aspirin, while mechanical valves require a combination of warfarin and aspirin.
Prosthetic Heart Valves: Options and Considerations
Prosthetic heart valves are commonly used to replace damaged or diseased valves in the heart. The two main options for replacement are biological (bioprosthetic) or mechanical valves. Bioprosthetic valves are usually derived from bovine or porcine sources and are preferred for 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 location. Aspirin is only given in addition if there is an additional indication, such as ischaemic heart disease.
It is important to consider the patient’s age, medical history, and lifestyle when choosing a prosthetic heart valve. While bioprosthetic valves may not require long-term anticoagulation, they may need to be replaced sooner than mechanical valves. Mechanical valves, on the other hand, may require lifelong anticoagulation, which can be challenging for some patients. Additionally, following the 2008 NICE guidelines, antibiotics are no longer recommended for common procedures such as dental work for prophylaxis of endocarditis. Therefore, it is crucial to weigh the benefits and risks of each option and make an informed decision with the patient.
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This question is part of the following fields:
- Cardiovascular Health
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Question 14
Incorrect
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A 67-year-old man presents for a medication review after being discharged from the hospital three months ago following a cholecystectomy. He was started on several new medications due to hypertension and atrial fibrillation. Despite feeling well, he has noticed ankle swelling and suspects it may be a side effect of one of the new medications.
During the examination, his blood pressure is 124/82 mmHg, and his heart rate is 68/min irregularly irregular.
Which medication is most likely responsible for the observed side effect?Your Answer:
Correct Answer: Felodipine
Explanation:Felodipine is more likely to cause ankle swelling than verapamil compared to dihydropyridines like amlodipine. Calcium channel blockers are commonly used as a first-line treatment for hypertension in patients over 55 years old, but a common side effect is peripheral edema. Dihydropyridines, such as amlodipine, work by selectively targeting vascular smooth muscle receptors, causing vasodilation and increased capillary pressure, which can lead to ankle edema. On the other hand, non-dihydropyridines like verapamil are more selective for myocardial calcium receptors, resulting in reduced cardiac contraction and heart rate.
Calcium channel blockers are a class of drugs commonly used to treat cardiovascular disease. These drugs target voltage-gated calcium channels found in myocardial cells, cells of the conduction system, and vascular smooth muscle. The different types of calcium channel blockers have varying effects on these areas, making it important to differentiate their uses and actions.
Verapamil is used to treat angina, hypertension, and arrhythmias. It is highly negatively inotropic and should not be given with beta-blockers as it may cause heart block. Side effects include heart failure, constipation, hypotension, bradycardia, and flushing.
Diltiazem is used to treat angina and hypertension. It is less negatively inotropic than verapamil, but caution should still be exercised when patients have heart failure or are taking beta-blockers. Side effects include hypotension, bradycardia, heart failure, and ankle swelling.
Nifedipine, amlodipine, and felodipine are dihydropyridines used to treat hypertension, angina, and Raynaud’s. They affect peripheral vascular smooth muscle more than the myocardium, which means they do not worsen heart failure but may cause ankle swelling. Shorter acting dihydropyridines like nifedipine may cause peripheral vasodilation, resulting in reflex tachycardia. Side effects include flushing, headache, and ankle swelling.
According to current NICE guidelines, the management of hypertension involves a flow chart that takes into account various factors such as age, ethnicity, and comorbidities. Calcium channel blockers may be used as part of the treatment plan depending on the individual patient’s needs.
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This question is part of the following fields:
- Cardiovascular Health
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Question 15
Incorrect
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You are contemplating prescribing sildenafil to a patient who is experiencing erectile dysfunction. He suffered a heart attack earlier this year but is not presently taking nitrates or nicorandil. What is the duration of time that NICE suggests we wait after a heart attack before prescribing a phosphodiesterase type 5 inhibitor?
Your Answer:
Correct Answer: 6 months
Explanation:Myocardial infarction (MI) is a serious condition that requires proper management to prevent further complications. The National Institute for Health and Care Excellence (NICE) has provided guidelines for the secondary prevention of MI. Patients who have had an MI should be offered dual antiplatelet therapy, ACE inhibitors, beta-blockers, and statins. Lifestyle changes such as following a Mediterranean-style diet and engaging in regular exercise are also recommended. Sexual activity may resume after four weeks, and PDE5 inhibitors may be used after six months, but caution should be exercised in patients taking nitrates or nicorandil.
Dual antiplatelet therapy is now the standard treatment for most patients who have had an acute coronary syndrome. Ticagrelor and prasugrel are now more commonly used as ADP-receptor inhibitors. The NICE Clinical Knowledge Summaries recommend adding ticagrelor to aspirin for medically managed patients and prasugrel or ticagrelor for those who have undergone percutaneous coronary intervention. The second antiplatelet should be stopped after 12 months, but this may be adjusted for patients at high risk of bleeding or further ischaemic events.
For patients who have had an acute MI and have symptoms and/or signs of heart failure and left ventricular systolic dysfunction, treatment with an aldosterone antagonist such as eplerenone should be initiated within 3-14 days of the MI, preferably after ACE inhibitor therapy. Proper management and adherence to these guidelines can significantly reduce the risk of further complications and improve the patient’s quality of life.
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This question is part of the following fields:
- Cardiovascular Health
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Question 16
Incorrect
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A 55-year-old woman presents to you for a follow-up blood pressure check. She has been evaluated by two other physicians in the past three months, with readings of 140/90 mmHg and 148/86 mmHg. Her current blood pressure is 142/84 mmHg. She has no familial history of hypertension, her BMI is 23, and she is a non-smoker. Based on the most recent NICE recommendations, what is the recommended course of action?
Your Answer:
Correct Answer: Check ECG and blood tests and see her again in a month with the results
Explanation:Understanding Hypertension Diagnosis and Management
Hypertension is a common condition that requires careful diagnosis and management. According to the 2019 NICE guidance on Hypertension (NG136), ambulatory or home blood pressure should be checked if a patient has a blood pressure equal to or greater than 140/90 mmHg. If the systolic reading is above 140 mmHg, it is considered a sign of hypertension.
The guidelines also state that lifestyle advice should be given to all patients, and drug treatment should be considered if there are signs of end organ damage or if the patient’s CVD risk is greater than 10% in 10 years. For patients under 40 years old, referral to a specialist should be considered.
It is important to note that NICE guidance is not the only source of information on hypertension diagnosis and management. While it is important to have an awareness of the latest guidance, it is also important to have a balanced view and consider other guidelines and consensus opinions.
In summary, understanding the diagnosis and management of hypertension is crucial for general practitioners. The 2019 NICE guidance on Hypertension provides important information on thresholds for diagnosis and management, but it is important to consider other sources of information as well.
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This question is part of the following fields:
- Cardiovascular Health
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Question 17
Incorrect
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A 50-year-old man presents for a routine check-up and inquires about the benefits and drawbacks of taking daily aspirin. He has normal blood pressure and his cholesterol and glucose levels are within normal limits.
What is the one accurate statement regarding the advantages and disadvantages of aspirin in primary prevention?Your Answer:
Correct Answer: Aspirin use in primary prevention reduces risk of non-fatal myocardial infarction
Explanation:The Pros and Cons of Aspirin in Primary Prevention
Aspirin has been found to reduce the risk of myocardial infarction in primary prevention studies. However, this benefit is counterbalanced by an increased risk of gastrointestinal bleeding, which is highest in the first 1-2 years of use but decreases with continued use. Despite this, there is a significant body of evidence indicating that aspirin can reduce the risk of cancer, particularly colorectal cancer, and also lower the risk of metastases. Additionally, stopping aspirin use can lead to a temporary increase in the risk of myocardial infarction. Currently, there is no consensus on whether aspirin or other antiplatelets should be recommended for primary prevention in otherwise healthy patients due to insufficient evidence.
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This question is part of the following fields:
- Cardiovascular Health
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Question 18
Incorrect
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A 55-year-old female patient presents to your morning clinic with complaints of pain and cramps in her right calf. She has also observed some brown discoloration around her right ankle. Her symptoms have been progressing for the past few weeks. She had been treated for a right-sided posterior tibial deep vein thrombosis (DVT) six months ago. Upon examination, she appears to be in good health.
What would be the best course of action for managing this patient?Your Answer:
Correct Answer: Compression stockings
Explanation:Compression stockings should only be offered to patients with deep vein thrombosis who are experiencing post-thrombotic syndrome (PTS), which typically occurs 6 months to 2 years after the initial DVT and is characterized by chronic pain, swelling, hyperpigmentation, and venous ulcers. Apixaban is not appropriate for treating PTS, as it is used to treat acute DVT. Codeine may help with pain but doesn’t address the underlying cause. Hirudoid cream is not effective for treating PTS, as it is used for superficial thrombophlebitis. If conservative management is not effective, patients may be referred to vascular surgery for surgical treatment. Compression stockings are the first-line treatment for PTS, as they improve blood flow and reduce symptoms in the affected calf.
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.
While compression stockings were previously recommended to reduce the risk of post-thrombotic syndrome in patients with DVT, Clinical Knowledge Summaries now advise against their use for this purpose. However, compression stockings are still recommended as a treatment for post-thrombotic syndrome. Other recommended treatments include keeping the affected leg elevated.
In summary, post-thrombotic syndrome is a potential complication of DVT that can cause a range of uncomfortable symptoms. While compression stockings are no longer recommended for prevention, they remain an important treatment option for those who develop the syndrome.
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This question is part of the following fields:
- Cardiovascular Health
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Question 19
Incorrect
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A 67-year-old man presents with shortness of breath.
An ECG shows atrial fibrillation (AF).
He takes digoxin, furosemide, and lisinopril.
What further drug would improve this patient's outcome?Your Answer:
Correct Answer: Abciximab
Explanation:Prophylactic Therapy for AF Patients with Heart Failure
The risk of embolic events in patients with heart failure and AF is high, with the risk of stroke increasing up to five-fold in non-rheumatic AF. The most appropriate prophylactic therapy for these patients is with an anticoagulant, such as warfarin.
According to studies, for every 1,000 patients with AF who are treated with warfarin for one year, 30 strokes are prevented at the expense of six major bleeds. On the other hand, for every 1,000 patients with AF who are treated with aspirin for one year, only 12.5 strokes are prevented at the expense of six major bleeds.
It is important to note that NICE guidelines on Atrial fibrillation (CG180) recommend warfarin, not aspirin, as the preferred prophylactic therapy for AF patients with heart failure.
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This question is part of the following fields:
- Cardiovascular Health
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Question 20
Incorrect
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A 53-year-old woman presents to the clinic with increasing shortness of breath. She enjoys walking her dog but has noticed a decrease in exercise tolerance. She reports experiencing fast, irregular palpitations at various times throughout the day.
During the examination, you observe flushed cheeks, a blood pressure reading of 140/95, and a raised JVP. You suspect the presence of a diastolic murmur. In a subsequent communication from the cardiologist, they describe a loud first heart sound, an opening snap, and a mid-diastolic rumble that is best heard at the apex.
What is the most probable diagnosis?Your Answer:
Correct Answer: Mitral stenosis
Explanation:Mitral Stenosis and Palpitations
The clinical presentation is indicative of mitral stenosis, with palpitations likely due to paroxysmal AF caused by an enlarged left atrium. The elevated JVP is a result of back pressure due to associated pulmonary hypertension. Left atrial myxoma, which is much rarer than mitral stenosis, is characterized by a tumour plop instead of an opening snap. Echocardiography is a crucial component of the diagnostic workup, allowing for the estimation of pressure across the valve, as well as left atrial size and right-sided pressures. AF prophylaxis and valve replacement are potential treatment options.
Spacing:
The clinical presentation is indicative of mitral stenosis, with palpitations likely due to paroxysmal AF caused by an enlarged left atrium. The elevated JVP is a result of back pressure due to associated pulmonary hypertension.
Left atrial myxoma, which is much rarer than mitral stenosis, is characterized by a tumour plop instead of an opening snap.
Echocardiography is a crucial component of the diagnostic workup, allowing for the estimation of pressure across the valve, as well as left atrial size and right-sided pressures.
AF prophylaxis and valve replacement are potential treatment options.
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This question is part of the following fields:
- Cardiovascular Health
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Question 21
Incorrect
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Choose the option that would be the LEAST probable reason for referring a patient with atrial fibrillation for rhythm control (cardioversion) if they were elderly.
Your Answer:
Correct Answer: Longstanding atrial fibrillation
Explanation:Cardioversion for Atrial Fibrillation: NICE Guidelines and Considerations
The National Institute for Health and Care Excellence (NICE) recommends referral to a cardiologist for rhythm-control treatment (cardioversion) in certain cases of atrial fibrillation. These include atrial fibrillation with a reversible cause, heart failure primarily caused or worsened by atrial fibrillation, and new-onset atrial fibrillation. If onset is known to be within 48 hours, referral to an acute medical unit is recommended for immediate cardioversion without anticoagulation treatment. Pharmacological cardioversion is often used as a first-line therapy, with electrical cardioversion reserved for non-responders. However, cardioversion may be less successful or not recommended in cases of long-standing atrial fibrillation, significant valve problems, cardiomegaly, or multiple recurrences of atrial fibrillation.
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This question is part of the following fields:
- Cardiovascular Health
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Question 22
Incorrect
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A 63-year-old man presents with a three-month history of palpitation. He reports feeling his heart skip a beat regularly but denies any other symptoms such as dizziness, shortness of breath, chest pain, or fainting.
Upon examination, his chest is clear and his oxygen saturation is 98%. Heart sounds are normal and there is no peripheral edema. His blood pressure is 126/64 mmHg and his ECG shows an irregularly irregular rhythm with no P waves and a heart rate of 82/min.
What is the most appropriate next step in managing this patient?Your Answer:
Correct Answer: Assessment using ORBIT bleeding risk tool and CHA2DS2-VASc tool
Explanation:To determine the need for anticoagulation in patients with atrial fibrillation, it is necessary to conduct an assessment using both the CHA2DS2-VASc tool and the ORBIT bleeding risk tool. This applies to all patients with atrial fibrillation, according to current NICE CKS guidance. Therefore, the option to commence on apixaban and bisoprolol is not correct.
The patient’s symptoms and ECG findings indicate atrial fibrillation, but there is no indication for a 24-hour ECG. Therefore, referral for a 24-hour ECG and commencing on apixaban and bisoprolol is not necessary.
As there are no signs or symptoms of heart failure and no evidence of valvular heart disease on examination, referral for an echocardiogram and commencing on apixaban and bisoprolol is not the appropriate option.
The patient is currently haemodynamically stable.
Atrial fibrillation (AF) is a condition that requires careful management, including the use of anticoagulation therapy. The latest guidelines from NICE recommend assessing the need for anticoagulation in all patients with a history of AF, regardless of whether they are currently experiencing symptoms. The CHA2DS2-VASc scoring system is used to determine the most appropriate anticoagulation strategy, with a score of 2 or more indicating the need for anticoagulation. However, it is important to ensure a transthoracic echocardiogram has been done to exclude valvular heart disease, which is an absolute indication for anticoagulation.
When considering anticoagulation therapy, doctors must also assess the patient’s bleeding risk. NICE recommends using the ORBIT scoring system to formalize this risk assessment, taking into account factors such as haemoglobin levels, age, bleeding history, renal impairment, and treatment with antiplatelet agents. While there are no formal rules on how to act on the ORBIT score, individual patient factors should be considered. The risk of bleeding increases with a higher ORBIT score, with a score of 4-7 indicating a high risk of bleeding.
For many years, warfarin was the anticoagulant of choice for AF. However, the development of direct oral anticoagulants (DOACs) has changed this. DOACs have the advantage of not requiring regular blood tests to check the INR and are now recommended as the first-line anticoagulant for patients with AF. The recommended DOACs for reducing stroke risk in AF are apixaban, dabigatran, edoxaban, and rivaroxaban. Warfarin is now used second-line, in patients where a DOAC is contraindicated or not tolerated. Aspirin is not recommended for reducing stroke risk in patients with AF.
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This question is part of the following fields:
- Cardiovascular Health
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Question 23
Incorrect
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A man attends the surgery for an 'MOT' having just had his 55th birthday. He is keen to reduce his risk of cardiovascular disease and asks about being started on a 'statin'.
He has no significant past medical history and takes no medication. His father had a 'heart attack' aged seventy, but his father was obese and a heavy smoker. There is no other family history of note. There is no suggestion of a familial lipid condition.
What is the most appropriate management approach at this point?Your Answer:
Correct Answer: Optimise adherence to diet and lifestyle measures
Explanation:Primary Prevention of Cardiovascular Disease
This patient has no history of cardiovascular disease (CVD), and therefore, the primary prevention approach is necessary. The first step is to use a CVD risk assessment tool such as QRISK2 to evaluate the patient’s cardiovascular risk. If the patient has a 10% or greater 10-year risk of developing CVD, measuring their lipid profile and offering atorvastatin 20 mg daily would be appropriate. Additionally, providing advice to optimize diet and lifestyle measures is necessary. However, if the patient’s risk is less than 10%, then diet and lifestyle advice/optimization in isolation would be appropriate. At this point, there is no specific indication for lipid clinic input. The use of QRISK2 in this scenario is the best approach as it guides the management, including whether pharmacological treatment with a statin is necessary.
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This question is part of the following fields:
- Cardiovascular Health
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Question 24
Incorrect
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A 67-year-old woman presents to the emergency department with a 3-day history of pain and swelling in her left lower leg. She denies any recent injury.
Upon examination, you observe that her left calf is swollen and red, measuring 3 cm larger in diameter than the right side. She experiences localised tenderness along the deep venous system.
Based on your clinical assessment, you suspect a deep vein thrombosis (DVT) and order blood tests, which reveal a D-Dimer level of 900 ng/mL (< 400).
You initiate treatment with therapeutic doses of apixaban and schedule a proximal leg ultrasound for the next day.
However, the ultrasound doesn't detect any evidence of a proximal leg DVT.
What is the most appropriate course of action?Your Answer:
Correct Answer: Stop apixaban and repeat ultrasound in 7 days
Explanation:Most isolated calf DVTs do not require treatment and resolve on their own, but in some cases, the clot may extend into the proximal veins and require medical intervention.
Deep vein thrombosis (DVT) is a serious condition that requires prompt diagnosis and management. The National Institute for Health and Care Excellence (NICE) updated their guidelines in 2020, recommending the use of direct oral anticoagulants (DOACs) as first-line treatment for most people with VTE, including as interim anticoagulants before a definite diagnosis is made. They also recommend the use of DOACs in patients with active cancer, as opposed to low-molecular weight heparin as was previously recommended. Routine cancer screening is no longer recommended following a VTE diagnosis.
If a patient is suspected of having a DVT, a two-level DVT Wells score should be performed to assess the likelihood of the condition. If a DVT is ‘likely’ (2 points or more), a proximal leg vein ultrasound scan should be carried out within 4 hours. If the result is positive, then a diagnosis of DVT is made and anticoagulant treatment should start. If the result is negative, a D-dimer test should be arranged. If a proximal leg vein ultrasound scan cannot be carried out within 4 hours, a D-dimer test should be performed and interim therapeutic anticoagulation administered whilst waiting for the proximal leg vein ultrasound scan (which should be performed within 24 hours).
The cornerstone of VTE management is anticoagulant therapy. The big change in the 2020 guidelines was the increased use of DOACs. Apixaban or rivaroxaban (both DOACs) should be offered first-line following the diagnosis of a DVT. Instead of using low-molecular weight heparin (LMWH) until the diagnosis is confirmed, NICE now advocate using a DOAC once a diagnosis is suspected, with this continued if the diagnosis is confirmed. If neither apixaban or rivaroxaban are suitable, then either LMWH followed by dabigatran or edoxaban OR LMWH followed by a vitamin K antagonist (VKA, i.e. warfarin) can be used.
All patients should have anticoagulation for at least 3 months. Continuing anticoagulation after this period is partly determined by whether the VTE was provoked or unprovoked. If the VTE was provoked, the treatment is typically stopped after the initial 3 months (3 to 6 months for people with active cancer). If the VTE was
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This question is part of the following fields:
- Cardiovascular Health
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Question 25
Incorrect
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A 63-year-old man has been feeling ill for 2 weeks with fatigue, loss of appetite, and night sweats. During examination, he has a temperature of 38.5oC and a loud mid-systolic ejection murmur in the second right intercostal space with a palpable thrill. What is the most appropriate intervention for this man?
Your Answer:
Correct Answer: Blood culture
Explanation:Possible Diagnosis of Infective Endocarditis and Criteria for Diagnosis
Infective endocarditis is a condition that involves inflammation of the heart valves caused by various organisms, including Streptococcus viridans. The lack of a dedicated blood supply to the valves reduces the immune response in these areas, making them susceptible to infection, especially if they are already damaged. A new or changing heart murmur, typical of aortic stenosis, may indicate the presence of infective endocarditis, particularly if accompanied by a fever.
To diagnose infective endocarditis, the Duke criteria require the presence of two major criteria, one major and three minor criteria, or five minor criteria. Major criteria include positive blood cultures with typical infective endocarditis microorganisms and evidence of vegetations on heart valves on an echocardiogram. Minor criteria include a predisposing factor such as a heart valve lesion or intravenous drug abuse, fever, embolism, immunological problems, or a single positive blood culture.
Immediate hospital admission is necessary for patients suspected of having infective endocarditis. Blood cultures should be taken before starting antibiotics, and an echocardiogram should be carried out urgently. While aortic stenosis is a common cause of heart murmurs, a new or changing murmur accompanied by a fever should raise suspicion of infective endocarditis.
Criteria for Diagnosing Infective Endocarditis
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This question is part of the following fields:
- Cardiovascular Health
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Question 26
Incorrect
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Raj is a 50-year-old man who has been prescribed an Antihypertensive medication for his high blood pressure. He visits you with a complaint of persistent bilateral ankle swelling for the past 3 weeks, which is causing him concern. Which of the following drugs is the probable cause of his new symptom?
Your Answer:
Correct Answer: Lacidipine
Explanation:Ankle swelling is more commonly associated with dihydropyridine calcium channel blockers like amlodipine than with verapamil. Although ankle oedema is a known side effect of all calcium channel blockers, there are differences in the incidence of ankle oedema between the two classes. Therefore, lacidipine, which belongs to the dihydropyridine class, is more likely to cause ankle swelling than verapamil.
Factors that increase the risk of developing ankle oedema while taking calcium channel blockers include being female, older age, having heart failure, standing upright, and being in warm environments.
Calcium channel blockers are a class of drugs commonly used to treat cardiovascular disease. These drugs target voltage-gated calcium channels found in myocardial cells, cells of the conduction system, and vascular smooth muscle. The different types of calcium channel blockers have varying effects on these areas, making it important to differentiate their uses and actions.
Verapamil is used to treat angina, hypertension, and arrhythmias. It is highly negatively inotropic and should not be given with beta-blockers as it may cause heart block. Side effects include heart failure, constipation, hypotension, bradycardia, and flushing.
Diltiazem is used to treat angina and hypertension. It is less negatively inotropic than verapamil, but caution should still be exercised when patients have heart failure or are taking beta-blockers. Side effects include hypotension, bradycardia, heart failure, and ankle swelling.
Nifedipine, amlodipine, and felodipine are dihydropyridines used to treat hypertension, angina, and Raynaud’s. They affect peripheral vascular smooth muscle more than the myocardium, which means they do not worsen heart failure but may cause ankle swelling. Shorter acting dihydropyridines like nifedipine may cause peripheral vasodilation, resulting in reflex tachycardia. Side effects include flushing, headache, and ankle swelling.
According to current NICE guidelines, the management of hypertension involves a flow chart that takes into account various factors such as age, ethnicity, and comorbidities. Calcium channel blockers may be used as part of the treatment plan depending on the individual patient’s needs.
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This question is part of the following fields:
- Cardiovascular Health
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Question 27
Incorrect
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A 60-year-old businessman has noticed a constricting discomfort in his throat, left shoulder and arm for the past few weeks when he exercises at the gym. He stops exercising and it goes away within five minutes. He has taken glyceryl trinitrate and finds it relieves the pain. His blood pressure is 158/94 mmHg and examination of the cardiovascular system and upper limbs is normal. He smokes 20 cigarettes per day.
Which of the following investigations is most appropriate to confirm this patient's most likely diagnosis?Your Answer:
Correct Answer: Computed tomography (CT) coronary angiography
Explanation:Diagnostic Tests for Stable Angina: CT Coronary Angiography, Non-Invasive Functional Imaging, ECG, Endoscopy, and Exercise ECG
Stable angina is suspected when a patient experiences constricting discomfort in the chest, neck, shoulders, jaw, or arms during physical exertion, which is relieved by rest or glyceryl trinitrate within five minutes. A typical angina diagnosis can be confirmed through a computed tomography (CT) coronary angiography, which should be offered if the patient exhibits typical or atypical angina or if the ECG shows ST-T changes or Q waves. Non-invasive functional imaging is recommended if the CT coronary angiography is not diagnostic or if the coronary artery disease is of uncertain functional significance. While ECG changes may suggest coronary artery disease, a normal ECG doesn’t confirm or exclude a diagnosis of stable angina. Endoscopy is used to investigate gastro-oesophageal causes of chest pain, but exercise-induced chest pain is more likely to be cardiac in nature. Exercise electrocardiograms are no longer recommended to diagnose or exclude stable angina in patients without known coronary artery disease.
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This question is part of the following fields:
- Cardiovascular Health
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Question 28
Incorrect
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A 28-year-old man walks into the General Practice Surgery without an appointment, complaining of central chest pain radiating to his jaw.
On examination, he is agitated. His respiratory rate is 26 breaths per minute (normal range 12–20) and his pulse is 130 beats per minute (normal range 60–100).
An electrocardiogram (ECG) confirms an ST-elevation myocardial infarction (STEMI). An accompanying friend suspects that the patient took a drug around 30 minutes previously but is unsure what it was.
Which of the following drugs is most likely to be responsible for this patient's symptoms?Your Answer:
Correct Answer: Cocaine
Explanation:Cardiovascular Risks Associated with Substance Abuse
Substance abuse can have significant impacts on cardiovascular health. Chronic cocaine use, for example, is a major risk factor for acute myocardial ischaemia, which can cause central chest pain, tachycardia, and other symptoms. Alcohol consumption, particularly binge-drinking, is also considered a cardiovascular risk factor, although it is not as strongly correlated with immediate effects as cocaine. Amphetamine and ecstasy intoxication can cause symptoms such as tachycardia, hyperthermia, and hypertension, and there have been reports of myocardial infarction associated with chronic use. Cannabis use can also cause tachycardia and other symptoms, but is rarely associated with MI. Overall, substance abuse can have serious consequences for cardiovascular health, particularly in men who are more likely to engage in drug use and dependence.
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This question is part of the following fields:
- Cardiovascular Health
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Question 29
Incorrect
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A 65-year-old man presents for review. He has been recently diagnosed with congestive heart failure. Currently, he takes digoxin 0.25 mg daily, furosemide 40 mg daily and amiloride 5 mg daily.
Routine laboratory studies are normal except for a blood urea of 8 mmol/l (2.5-7.5) and a serum creatinine of 110 μmol/L (60-110).
One month later, the patient continues to have dyspnoea and orthopnoea and has noted a 4 kg reduction in weight. His pulse rate is 96 per minute, blood pressure is 132/78 mmHg. Physical examination is unchanged except for reduced crackles, JVP is no longer visible and there is no ankle oedema.
Repeat investigations show:
Urea 10.5 mmol/L (2.5-7.5)
Creatinine 120 µmol/L (60-110)
Sodium 135 mmol/L (137-144)
Potassium 3.5 mmol/L (3.5-4.9)
Digoxin concentration within therapeutic range.
What would be the next most appropriate change to make to his medication?Your Answer:
Correct Answer: Add lisinopril 2.5 mg daily
Explanation:The Importance of ACE Inhibitors in Heart Failure Treatment
Angiotensin converting enzyme (ACE) inhibitors are crucial drugs in the treatment of heart failure. They offer a survival advantage and are the primary treatment for heart failure, unless contraindicated. These drugs work by reducing peripheral vascular resistance through the blockage of the angiotensin converting enzyme. This action decreases myocardial oxygen consumption, improving cardiac output and moderating left ventricular and vascular hypertrophy.
ACE inhibitors are particularly effective in treating congestive heart failure (CHF) caused by systolic dysfunction. However, first dose hypotension may occur, especially if the patient is already on diuretics. These drugs are also beneficial in protecting renal function, especially in cases of significant proteinuria. An increase of 20% in serum creatinine levels is not uncommon and is not a reason to discontinue the medication.
It is important to note that potassium levels can be affected by ACE inhibitors, and this patient is already taking several drugs that can alter potassium levels. The introduction of an ACE inhibitor may increase potassium levels, which would need to be monitored carefully. If potassium levels become too high, the amiloride may need to be stopped or substituted with a higher dose of furosemide. Overall, ACE inhibitors play a crucial role in the treatment of heart failure and should be carefully monitored to ensure their effectiveness and safety.
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This question is part of the following fields:
- Cardiovascular Health
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Question 30
Incorrect
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A 30-year-old healthy woman visits her General Practitioner to obtain a health insurance policy. She has no significant medical history, is a non-smoker, and drinks 3 units of alcohol weekly. During examination, a faint systolic murmur is detected. Her ECG shows a heart rate of 68 bpm and is normal. An echocardiogram reveals a bicuspid aortic valve.
What is the most appropriate management option for this patient?Your Answer:
Correct Answer: Referral for heart surgery at a later date
Explanation:Bicuspid Aortic Valve: Risks and Recommendations
Bicuspid aortic valve is a common congenital heart disease in adults, occurring in 1-2% of the population with a familial incidence of around 10%. While some patients may be asymptomatic, about 30% develop complications such as aortic stenosis or insufficiency, which may require surgery. Additionally, the aorta of patients with bicuspid aortic valve has reduced tensile strength, putting them at higher risk for aortic dissection and aneurysm formation in the ascending aorta.
To manage the cardiovascular risk associated with this condition, low-dose aspirin and cholesterol-lowering drugs may be prescribed as appropriate. While there is evidence supporting a familial predisposition, screening for family members is not yet universally recommended. Finally, while infective endocarditis is a potential complication, antibiotic prophylaxis during dental procedures is no longer recommended.
In summary, bicuspid aortic valve requires careful monitoring and management to prevent complications and ensure optimal cardiovascular health.
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This question is part of the following fields:
- Cardiovascular Health
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