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  • Question 1 - A 48-year-old man presents to the hypertension clinic with a recent diagnosis of...

    Correct

    • A 48-year-old man presents to the hypertension clinic with a recent diagnosis of high blood pressure. He has been on ramipril for three months, but despite titration up to 10 mg od, his blood pressure remains elevated at 156/92 mmHg.

      What would be the most suitable course of action for further management?

      Your Answer: Add amlodipine OR indapamide

      Explanation:

      To improve control of hypertension in patients who are already taking an ACE inhibitor or an angiotensin receptor blocker, the 2019 NICE guidelines recommend adding either a calcium channel blocker (such as amlodipine) or a thiazide-like diuretic (such as indapamide). This is a change from previous guidelines, which only recommended adding a calcium channel blocker in this situation.

      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.

    • This question is part of the following fields:

      • Cardiovascular Health
      71.9
      Seconds
  • Question 2 - You see a 65-year-old man in a 'hypertension review' appointment. You have been...

    Incorrect

    • You see a 65-year-old man in a 'hypertension review' appointment. You have been struggling to control his blood pressure. He is now taking valsartan 320 mg (his initial ACE inhibitor, Perindopril, was stopped due to persistent coughing), amlodipine 10 mg and chlorthalidone 12.5 mg. He is also taking aspirin and simvastatin for primary prevention. His blood pressure today is 158/91. His recent renal function (done for annual hypertension) showed a sodium of 138, a potassium of 4.7, a urea of 4.2 and a creatinine of 80. His eGFR is 67. He is otherwise well in himself.

      Which of the following options would be appropriate for him?

      Your Answer: Add bisoprolol

      Correct Answer: Try ramipril

      Explanation:

      Managing Resistant Hypertension

      Resistant hypertension can be a challenging condition to manage, often requiring up to four different Antihypertensive agents. If a person is already taking three Antihypertensive drugs and their blood pressure is still not controlled, increasing chlorthalidone to a maximum of 50 mg may be considered, provided that blood potassium levels are higher than 4.5mmol/L. However, caution should be exercised when using co-amilofruse, a potassium-sparing diuretic, in conjunction with valsartan, especially if the patient has a recent history of having a potassium level of 4.5 or higher.

      If a patient has previously developed a cough with an ACE inhibitor, switching to a different ACE inhibitor is unlikely to make any difference. In such cases, bisoprolol may be added if further diuretic treatment is not tolerated, is contraindicated, or is ineffective. It is important to seek specialist advice if secondary causes for hypertension are likely or if a patient’s blood pressure is not controlled on the optimal or maximum tolerated doses of four Antihypertensive drugs.

    • This question is part of the following fields:

      • Cardiovascular Health
      64.7
      Seconds
  • Question 3 - A 55-year-old man presents to his General Practitioner to discuss the uptitration of...

    Correct

    • A 55-year-old man presents to his General Practitioner to discuss the uptitration of his medication as advised by cardiology. He suffered an anterior myocardial infarction (MI) four weeks ago. His history reveals that he is a smoker (20 per day for 30 years) and works in a sedentary office job, where he often works long days and eats ready meals to save time with food preparation.
      On examination, his heart rate is 62 bpm and his blood pressure is 126/74 mmHg, body mass index (BMI) is 31. His bisoprolol is increased to 5 mg and ramipril to 7.5 mg.
      Which of the following is the single non-pharmacological intervention that will be most helpful in reducing his risk of a future ischaemic event?

      Your Answer: Stopping smoking

      Explanation:

      Reducing Cardiovascular Risk: Lifestyle Changes to Consider

      Cardiovascular disease (CVD) is a leading cause of death worldwide, but many of the risk factors are modifiable through lifestyle changes. The three most important modifiable and causal risk factors are smoking, hypertension, and abnormal lipids. While hypertension and abnormal lipids may require medication to make significant changes, smoking cessation is the single most important non-pharmacological, modifiable risk factor in reducing cardiovascular risk.

      In addition to quitting smoking, there are other lifestyle changes that can help reduce cardiovascular risk. A cardioprotective diet should limit total fat intake to 30% or less of total energy intake, with saturated fat intake below 7%. Low-carbohydrate dietary intake is also thought to be important in cardiovascular disease prevention.

      Regular exercise is also important, with 150 minutes or more per week of moderate-intensity aerobic activity and muscle-strengthening activities on at least two days a week recommended. While exercise is beneficial, stopping smoking remains the most effective lifestyle change for reducing cardiovascular risk.

      Salt restriction can also help reduce risk, with a recommended intake of less than 6 g per day. Patients should be advised to avoid adding salt to their meals and minimize processed foods.

      Finally, weight reduction should be advised to decrease future cardiovascular risk, with a goal of achieving a normal BMI. Obese patients should also be assessed for sleep apnea. By making these lifestyle changes, individuals can significantly reduce their risk of developing cardiovascular disease.

    • This question is part of the following fields:

      • Cardiovascular Health
      63
      Seconds
  • Question 4 - Which of the following combination of symptoms is most consistent with digoxin toxicity?...

    Correct

    • Which of the following combination of symptoms is most consistent with digoxin toxicity?

      Your Answer: Nausea + yellow / green vision

      Explanation:

      Understanding Digoxin and Its Toxicity

      Digoxin is a medication used for rate control in atrial fibrillation and for improving symptoms in heart failure patients. It works by decreasing conduction through the atrioventricular node and increasing the force of cardiac muscle contraction. However, it has a narrow therapeutic index and can cause toxicity even when the concentration is within the therapeutic range.

      Toxicity may present with symptoms such as lethargy, nausea, vomiting, confusion, and yellow-green vision. Arrhythmias and gynaecomastia may also occur. Hypokalaemia is a classic precipitating factor as it increases the inhibitory effects of digoxin. Other factors include increasing age, renal failure, myocardial ischaemia, and various electrolyte imbalances. Certain drugs, such as amiodarone and verapamil, can also contribute to toxicity.

      If toxicity is suspected, digoxin concentrations should be measured within 8 to 12 hours of the last dose. However, plasma concentration alone doesn’t determine toxicity. Management includes the use of Digibind, correcting arrhythmias, and monitoring potassium levels.

      In summary, understanding the mechanism of action, monitoring, and potential toxicity of digoxin is crucial for its safe and effective use in clinical practice.

    • This question is part of the following fields:

      • Cardiovascular Health
      13.3
      Seconds
  • Question 5 - A 78-year-old man comes to you to discuss blood pressure management.

    He has...

    Incorrect

    • A 78-year-old man comes to you to discuss blood pressure management.

      He has been seen by the nurse three times in the past six months, and each time his BP has been above 160/95 mmHg. He has no significant medical history except for a hernia repair eight years ago. He complains of mild dyspnea on exertion and mild ankle swelling at the end of the day.

      During today's examination, his BP is 155/92 mmHg, his pulse is 70 and regular, and his BMI is 27 kg/m2.

      Investigations reveal:
      - Hb 123 g/L (135 - 180)
      - WCC 5.1 ×109/L (4 - 10)
      - PLT 190 ×109/L (150 - 400)
      - Na 141 mmol/L (134 - 143)
      - K 4.5 mmol/L (3.5 - 5.0)
      - Cr 145 µmol/L (60 - 120)

      What is the best course of action for managing this man's blood pressure?

      Your Answer: Indapamide 2.5 mg is an appropriate therapy choice

      Correct Answer: If BP target is not reached on two or more agents than addition of more drugs is of no value

      Explanation:

      Treating Hypertension in Elderly Patients

      Patients of all ages should be treated to target when it comes to hypertension. The NICE guidelines on Hypertension (NG136) recommend a clinic blood pressure (BP) of less than 150/90 mmHg for patients over the age of 80. For patients over 55, calcium channel antagonists are the most appropriate first-line therapies, unless there is evidence of oedema, heart failure, or the patient is at risk of heart failure. In such cases, a thiazide-like diuretic such as chlorthalidone or indapamide should be used instead of conventional thiazides like bendroflumethiazide and hydrochlorothiazide. If a CCB is not tolerated, a thiazide-like diuretic should be offered to treat hypertension. Indapamide is a thiazide-like diuretic that is associated with less hyponatraemia compared to bendroflumethiazide, making it an appropriate choice for first-line therapy in elderly patients. Even if the target BP is not reached on two or more agents, it is important to continue therapy.

    • This question is part of the following fields:

      • Cardiovascular Health
      139.1
      Seconds
  • Question 6 - A 78-year-old gentleman visited his GP last week and was referred for 24...

    Correct

    • A 78-year-old gentleman visited his GP last week and was referred for 24 hour ambulatory blood pressure monitoring. The results showed a daytime average of 144/82 mmHg. He is currently taking amlodipine 10 mg once a day and ramipril 10 mg once a day. What would be the best course of action for managing this patient?

      Your Answer: Continue current therapy

      Explanation:

      ABPM vs Solitary Clinic Blood Pressure

      Note the difference between a solitary clinic blood pressure and ABPM. ABPM stands for ambulatory blood pressure monitoring, which is a method of measuring blood pressure over a 24-hour period. This is different from a solitary clinic blood pressure, which is taken in a medical setting at a single point in time.

      For patients over the age of 80, their daytime average ABPM or average HBPM (hospital blood pressure monitoring) blood pressure should be less than 145/85 mmHg. This is according to NICE guidelines, which state that for people under 80 years old, the daytime average ABPM or average HBPM blood pressure should be lower than 135/85 mmHg.

      It’s important to note that ABPM targets are different from clinic BP targets. This is because ABPM provides a more accurate and comprehensive picture of a patient’s blood pressure over a 24-hour period, rather than just a single reading in a medical setting. By using ABPM, healthcare professionals can better monitor and manage a patient’s blood pressure, especially for those over the age of 80.

    • This question is part of the following fields:

      • Cardiovascular Health
      27.9
      Seconds
  • Question 7 - A 56-year-old man collapses in the hospital during a nurse-led hypertension clinic. He...

    Correct

    • A 56-year-old man collapses in the hospital during a nurse-led hypertension clinic. He is unresponsive and has no pulse in his carotid artery. What is the appropriate ratio of chest compressions to ventilation?

      Your Answer: 30:02:00

      Explanation:

      The 2015 Resus Council guidelines for adult advanced life support outline the steps to be taken in the event of a cardiac arrest. Patients are divided into those with ‘shockable’ rhythms (ventricular fibrillation/pulseless ventricular tachycardia) and ‘non-shockable’ rhythms (asystole/pulseless-electrical activity). Key points include the ratio of chest compressions to ventilation (30:2), continuing chest compressions while a defibrillator is charged, and delivering drugs via IV access or the intraosseous route. Adrenaline and amiodarone are recommended for non-shockable rhythms and VF/pulseless VT, respectively. Thrombolytic drugs should be considered if a pulmonary embolism is suspected. Atropine is no longer recommended for routine use in asystole or PEA. Following successful resuscitation, oxygen should be titrated to achieve saturations of 94-98%. The ‘Hs’ and ‘Ts’ outline reversible causes of cardiac arrest, including hypoxia, hypovolaemia, and thrombosis.

    • This question is part of the following fields:

      • Cardiovascular Health
      17.3
      Seconds
  • Question 8 - A 50-year-old woman has been diagnosed with an unprovoked proximal deep vein thrombosis....

    Correct

    • A 50-year-old woman has been diagnosed with an unprovoked proximal deep vein thrombosis. What are the available treatment options for this condition?

      Your Answer: Warfarin or Rivaroxaban or Dabigatran or Apixaban

      Explanation:

      Direct oral anticoagulants (DOACs) are medications used to prevent stroke in non-valvular atrial fibrillation (AF), as well as for the prevention and treatment of venous thromboembolism (VTE). To be prescribed DOACs for stroke prevention, patients must have certain risk factors, such as a prior stroke or transient ischaemic attack, age 75 or older, hypertension, diabetes mellitus, or heart failure. There are four DOACs available, each with a different mechanism of action and method of excretion. Dabigatran is a direct thrombin inhibitor, while rivaroxaban, apixaban, and edoxaban are direct factor Xa inhibitors. The majority of DOACs are excreted either through the kidneys or the liver, with the exception of apixaban and edoxaban, which are excreted through the feces. Reversal agents are available for dabigatran and rivaroxaban, but not for apixaban or edoxaban.

    • This question is part of the following fields:

      • Cardiovascular Health
      31
      Seconds
  • Question 9 - A patient with long-standing chronic obstructive pulmonary disease (COPD) who is in their...

    Incorrect

    • A patient with long-standing chronic obstructive pulmonary disease (COPD) who is in their 60s now presents with symptoms of right heart failure. Upon examination, they are in sinus rhythm but have peripheral edema, a raised JVP, and a loud pulmonary second heart sound. The diagnosis is cor pulmonale. What is the recommended treatment for right heart failure that develops as a result of lung disease?

      Your Answer: Alpha blocker

      Correct Answer: Angiotensin converting enzyme inhibitor

      Explanation:

      Managing Oedema in Cor Pulmonale Patients

      Patients with oedema caused by cor pulmonale can be treated with diuretic therapy. However, according to NICE guidelines on Chronic obstructive pulmonary disease (NG115), ACE inhibitors, alpha blockers, and calcium channel blockers should not be used. Digoxin should only be prescribed if the patient also has atrial fibrillation.

      It is important to assess patients for long-term oxygen therapy to manage their condition effectively. For more information on managing oedema in cor pulmonale patients, please refer to the NICE guidelines on Chronic obstructive pulmonary disease (NG115).

    • This question is part of the following fields:

      • Cardiovascular Health
      43.8
      Seconds
  • Question 10 - An 80-year-old man who is currently taking warfarin inquires about the feasibility of...

    Correct

    • An 80-year-old man who is currently taking warfarin inquires about the feasibility of switching to dabigatran to eliminate the requirement for regular INR testing.

      What would be a contraindication to prescribing dabigatran in this scenario?

      Your Answer: Mechanical heart valve

      Explanation:

      Patients with mechanical heart valves should avoid using dabigatran due to its increased risk of bleeding and thrombotic events compared to warfarin. The MHRA has deemed it contraindicated for this population.

      Dabigatran: An Oral Anticoagulant with Two Main Indications

      Dabigatran is an oral anticoagulant that directly inhibits thrombin, making it an alternative to warfarin. Unlike warfarin, dabigatran doesn’t require regular monitoring. It is currently used for two main indications. Firstly, it is an option for prophylaxis of venous thromboembolism following hip or knee replacement surgery. Secondly, it is licensed for prevention of stroke in patients with non-valvular atrial fibrillation who have one or more risk factors present. The major adverse effect of dabigatran is haemorrhage, and doses should be reduced in chronic kidney disease. Dabigatran should not be prescribed if the creatinine clearance is less than 30 ml/min. In cases where rapid reversal of the anticoagulant effects of dabigatran is necessary, idarucizumab can be used. However, the RE-ALIGN study showed significantly higher bleeding and thrombotic events in patients with recent mechanical heart valve replacement using dabigatran compared with warfarin. As a result, dabigatran is now contraindicated in patients with prosthetic heart valves.

    • This question is part of the following fields:

      • Cardiovascular Health
      59.9
      Seconds
  • Question 11 - A 57-year-old man visits his GP for a blood pressure check. He has...

    Incorrect

    • A 57-year-old man visits his GP for a blood pressure check. He has a medical history of hypothyroidism, asthma, and high cholesterol. He reports feeling well, and his QRISK score is calculated at 11%.

      The patient is currently taking levothyroxine, atorvastatin, lercanidipine, beclomethasone, and salbutamol. He has no known allergies.

      After taking three readings, his blood pressure averages at 146/92 mmHg.

      What is the most appropriate course of action?

      Your Answer:

      Correct Answer: Addition of losartan

      Explanation:

      The patient’s current therapy doesn’t affect the treatment decision, but an additional medication from either the ACE-inhibitor or angiotensin receptor blocker class is recommended to control their blood pressure. According to updated guidelines from 2019, a thiazide-like diuretic may also be used. As losartan is the only medication from these classes, it is the correct choice. Bisoprolol, doxazosin, and spironolactone are typically reserved for cases of resistant hypertension that do not respond to combinations of a calcium channel blocker, a thiazide-like diuretic, and an ACE-inhibitor or angiotensin receptor blocker. Since the patient is only on a single therapy, adding any of these options is not currently indicated. Choosing to make no changes to the medication is incorrect, as the patient’s blood pressure remains above the target range of 140/90 mmHg.

      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.

    • This question is part of the following fields:

      • Cardiovascular Health
      0
      Seconds
  • Question 12 - A 67-year old man with hypertension visited his general practitioner after an ambulatory...

    Incorrect

    • A 67-year old man with hypertension visited his general practitioner after an ambulatory blood pressure monitor showed a daytime average blood pressure of 155/98 mmHg. Despite taking optimal doses of ramipril and amlodipine with good adherence, which medication should be introduced to his treatment plan?

      Your Answer:

      Correct Answer: Indapamide

      Explanation:

      To improve the management of hypertension that is not well-controlled despite the use of an ACE inhibitor and a calcium channel blocker, it is recommended to include a thiazide-like diuretic.

      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.

    • This question is part of the following fields:

      • Cardiovascular Health
      0
      Seconds
  • Question 13 - A 85-year-old gentleman with advanced dementia was found to have bradycardia during a...

    Incorrect

    • A 85-year-old gentleman with advanced dementia was found to have bradycardia during a routine medical check-up. The patient did not show any symptoms and his general examination was unremarkable. He is currently taking atorvastatin and galantamine. An ECG taken at rest showed sinus bradycardia with a rate of 56 beats per minute. Blood tests, including electrolytes, calcium, magnesium, and thyroid function, were all within normal limits.

      What is the MOST APPROPRIATE NEXT step in management? Choose ONE option only.

      Your Answer:

      Correct Answer: Stop galantamine and inform memory clinic

      Explanation:

      Sinus Bradycardia and its Management

      Sinus bradycardia is a condition where the heart rate is slower than normal. If the cause of sinus bradycardia is unknown and it doesn’t cause any symptoms, no intervention may be required. However, more information is needed before making a decision. A 24-hour ECG can be useful in characterizing the heart rhythm, but it may take several days to organize as an outpatient.

      There is no need to discuss sinus bradycardia with the on-call team unless the patient experiences symptoms such as dizziness, shortness of breath, or chest pain, or if there is evidence of heart failure. It is important to note that statins are not associated with bradycardia, but all AChEs are associated with it, and withholding the drug is necessary if bradycardia occurs.

    • This question is part of the following fields:

      • Cardiovascular Health
      0
      Seconds
  • Question 14 - A 65-year old man has had syncopal attacks and exertional chest pain which...

    Incorrect

    • A 65-year old man has had syncopal attacks and exertional chest pain which settles spontaneously with rest. He presents to his General Practitioner, not wanting to bother the Emergency Department. On auscultation, there is a loud ejection systolic murmur. Following an electrocardiogram (ECG) he is urgently referred to cardiology and aortic stenosis is diagnosed.
      Given the likely diagnosis, which of the following comorbid conditions is most associated with a poor prognosis?

      Your Answer:

      Correct Answer: Left ventricular failure

      Explanation:

      Understanding Prognostic Factors in Aortic Stenosis

      Aortic stenosis is a condition characterized by the narrowing of the aortic valve, which can lead to limited blood flow and various symptoms such as dyspnea, angina, and syncope. While patients may be asymptomatic for years, the prognosis for symptomatic aortic stenosis is poor, with a 2-year survival rate of only 50%. Sudden deaths can occur due to heart failure or other complications.

      Valvular calcification and fibrosis are the primary causes of aortic stenosis, and the presence of calcification doesn’t have a direct impact on prognosis. However, mixed aortic valve disease, which includes aortic regurgitation, can increase mortality rates, particularly in severe cases.

      Left ventricular failure is a significant prognostic factor in aortic stenosis, indicating late-stage hypertrophy and fibrosis. Patients with left ventricular failure have a poor prognosis both before and after surgery. Hypertension can also impact left ventricular remodelling and accelerate the progression of aortic stenosis, but it is not as significant a prognostic factor as left ventricular failure.

      Electrocardiogram (ECG) changes, such as left ventricular hypertrophy, are common in patients with aortic stenosis but are not directly correlated with mortality risk. Understanding these prognostic factors can help healthcare providers better manage and treat patients with aortic stenosis.

    • This question is part of the following fields:

      • Cardiovascular Health
      0
      Seconds
  • Question 15 - A 79-year-old man is being seen in the hypertension clinic. What is the...

    Incorrect

    • A 79-year-old man is being seen in the hypertension clinic. What is the recommended target blood pressure for him once he starts treatment?

      Your Answer:

      Correct Answer: 150/90 mmHg

      Explanation:

      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.

    • This question is part of the following fields:

      • Cardiovascular Health
      0
      Seconds
  • Question 16 - A 50-year-old male is being reviewed after being admitted six weeks ago with...

    Incorrect

    • A 50-year-old male is being reviewed after being admitted six weeks ago with an inferior myocardial infarction (MI) and treated with thrombolysis. He has been prescribed atenolol 50 mg daily, aspirin, and rosuvastatin 10 mg daily upon discharge. He has quit smoking after his MI and is now asking which foods he should avoid.

      Your Answer:

      Correct Answer: Kippers

      Explanation:

      Diet Recommendations Following a Heart Attack

      Following a heart attack, it is important for patients to make dietary changes to reduce the risk of another cardiac event. One of the key recommendations is to avoid foods high in saturated fat, such as cheese, milk, and fried foods. Instead, patients should switch to a diet rich in high-fiber, starch-based foods, and aim to consume five portions of fresh fruits and vegetables daily, as well as oily fish.

      However, it is important to note that NICE guidance on Acute Coronary Syndromes (NG185) advises against the use of omega-3 capsules and supplements to prevent another heart attack. While oily fish is still recommended as a source of omega-3, patients should not rely on supplements as a substitute for a healthy diet. By making these dietary changes, patients can improve their heart health and reduce the risk of future cardiac events.

    • This question is part of the following fields:

      • Cardiovascular Health
      0
      Seconds
  • Question 17 - You assess a 63-year-old man who has recently been released from a hospital...

    Incorrect

    • You assess a 63-year-old man who has recently been released from a hospital in Hungary after experiencing a heart attack. He presents a copy of an echocardiogram report indicating that his left ventricular ejection fraction is 38%. During the examination, you note that his pulse is regular at 78 beats per minute, his blood pressure is 124/72 mmHg, and his chest is clear. He is currently taking aspirin, simvastatin, and lisinopril. What would be the most appropriate course of action regarding his medication?

      Your Answer:

      Correct 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.

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

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 18 - A 72 year old woman presents to your clinic complaining of ankle swelling...

    Incorrect

    • A 72 year old woman presents to your clinic complaining of ankle swelling that has persisted for the past 2 weeks. The swelling is present in both ankles and there is pitting edema up to the mid-shin. She recently had a modification in her medication 2 weeks ago. Which medication is the most probable cause of this symptom?

      Your Answer:

      Correct Answer: Amlodipine

      Explanation:

      Ankle oedema is not a known side effect of bendroflumethiazide. However, it may cause postural hypotension and electrolyte imbalances, particularly hypokalaemia.

      Beta blockers such as bisoprolol do not typically cause ankle oedema. They may cause peripheral coldness due to vasoconstriction, hypotension, and bronchospasm.

      Clopidogrel is not associated with ankle oedema. However, it may cause gastrointestinal symptoms or bleeding disorders in rare cases.

      ACE inhibitors like ramipril may cause hypotension, renal dysfunction, and a dry cough. They are not typically associated with ankle oedema.

      Amlodipine, a calcium channel blocker, is known to cause ankle oedema, which may not respond fully to diuretics. It may also cause other side effects related to vasodilation, such as flushing and headaches.

      References: BNF

      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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      • Cardiovascular Health
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  • Question 19 - During a late-night shift at an urgent care centre, you encounter a 30-year-old...

    Incorrect

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

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

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

      Your Answer:

      Correct Answer: Prescribe apixaban

      Explanation:

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

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

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

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

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

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      • Cardiovascular Health
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  • Question 20 - A 65-year-old female presents to the rapid access transient ischaemic attack clinic with...

    Incorrect

    • A 65-year-old female presents to the rapid access transient ischaemic attack clinic with a history of transient loss of vision in the right eye over the past three weeks. Upon examination, a carotid ultrasound reveals a 48% stenosis of her right carotid artery and an ECG shows sinus rhythm. The patient was initiated on aspirin 300 mg od by her GP after the first episode. What is the optimal course of action for managing this patient?

      Your Answer:

      Correct Answer: Clopidogrel

      Explanation:

      According to NICE Clinical Knowledge Summaries, patients diagnosed with ischaemic stroke or TIA without paroxysmal or permanent atrial fibrillation should be prescribed antiplatelet therapy for long-term vascular prevention. The standard treatment is clopidogrel 75 mg daily, which is licensed for use in ischaemic stroke and can be used off-label for TIA. If clopidogrel and aspirin are contraindicated or cannot be tolerated, modified-release dipyridamole 200 mg twice daily may be used. Aspirin 75 mg daily can be used if both clopidogrel and modified-release dipyridamole are contraindicated or cannot be tolerated. If clopidogrel cannot be tolerated, aspirin 75 mg daily with modified-release dipyridamole 200 mg twice daily may be used. The 2012 Royal College of Physicians National clinical guidelines for stroke now recommend using clopidogrel following a TIA, which aligns with current stroke guidance.

      A transient ischaemic attack (TIA) is a brief period of neurological deficit caused by a vascular issue, lasting less than an hour. The original definition of a TIA was based on time, but it is now recognized that even short periods of ischaemia can result in pathological changes to the brain. Therefore, a new ’tissue-based’ definition is now used. The clinical features of a TIA are similar to those of a stroke, but the symptoms resolve within an hour. Possible features include unilateral weakness or sensory loss, aphasia or dysarthria, ataxia, vertigo, or loss of balance, visual problems, sudden transient loss of vision in one eye (amaurosis fugax), diplopia, and homonymous hemianopia.

      NICE recommends immediate antithrombotic therapy, giving aspirin 300 mg immediately unless the patient has a bleeding disorder or is taking an anticoagulant. If aspirin is contraindicated, management should be discussed urgently with the specialist team. Specialist review is necessary if the patient has had more than one TIA or has a suspected cardioembolic source or severe carotid stenosis. Urgent assessment within 24 hours by a specialist stroke physician is required if the patient has had a suspected TIA in the last 7 days. Referral for specialist assessment should be made as soon as possible within 7 days if the patient has had a suspected TIA more than a week previously. The person should be advised not to drive until they have been seen by a specialist.

      Neuroimaging should be done on the same day as specialist assessment if possible. MRI is preferred to determine the territory of ischaemia or to detect haemorrhage or alternative pathologies. Carotid imaging is necessary as atherosclerosis in the carotid artery may be a source of emboli in some patients. All patients should have an urgent carotid doppler unless they are not a candidate for carotid endarterectomy.

      Antithrombotic therapy is recommended, with clopidogrel being the first-line treatment. Aspirin + dipyridamole should be given to patients who cannot tolerate clopidogrel. Carotid artery endarterectomy should only be considered if the patient has suffered a stroke or TIA in the carotid territory and is not severely disabled. It should only be recommended if carotid stenosis is greater

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      • Cardiovascular Health
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  • Question 21 - A 28-year-old man comes to the clinic complaining of pain in both lower...

    Incorrect

    • A 28-year-old man comes to the clinic complaining of pain in both lower legs while running. The pain gradually intensifies after a brief period of running, causing him to stop. However, the pain quickly subsides when he is at rest. Upon examination, there are no abnormal findings, and his peripheral pulses are all palpable. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Osgood-Schlatter's disease

      Explanation:

      Chronic Exertional Compartment Syndrome

      Chronic exertional compartment syndrome (CECS) is a condition that causes exertional leg pain due to the fascial compartment being unable to accommodate the increased volume of the muscle during exercise. It is often mistaken for peripheral arterial disease.

      If you experience exertional leg pain with tenderness over the middle of the muscle compartment but no bony tenderness, it may be a sign of CECS. This condition should be suspected when there is no evidence of tibial tuberosity pain, which is common in Osgood-Schlatter’s disease.

      Referral for pre- and post-exertional pressure testing may be necessary, and if conservative measures are unsuccessful, a fasciotomy may be required.

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      • Cardiovascular Health
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  • Question 22 - Samantha is a 64-year-old woman who presents to you with a new-onset headache...

    Incorrect

    • Samantha is a 64-year-old woman who presents to you with a new-onset headache that started 3 weeks ago. Samantha's medical history includes type 2 diabetes and hypercholesterolaemia, and she has a body mass index of 29 kg/m².

      During your examination, you measure Samantha's blood pressure which is 190/118 mmHg. A repeat reading shows 186/116 mmHg. Upon conducting fundoscopy, you observe evidence of retinal haemorrhage.

      What would be the most appropriate initial management?

      Your Answer:

      Correct Answer: Refer for same-day specialist assessment

      Explanation:

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

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

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

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

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

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 23 - A 62-year-old woman comes to the General Practitioner for a medication consultation. She...

    Incorrect

    • A 62-year-old woman comes to the General Practitioner for a medication consultation. She has recently suffered a non-ST-elevation myocardial infarction. She has no other significant conditions and prior to this event was not taking medication or known to have cardiovascular disease. Her blood pressure is 140/85 mmHg and her fasting cholesterol is 5.2 mmol/l.
      Which of the following is the most appropriate treatment to reduce the risk of further events?

      Your Answer:

      Correct Answer: Ramipril, atenolol, aspirin and clopidogrel and atorvastatin

      Explanation:

      Recommended Drug Treatment for Secondary Prevention of Myocardial Infarction

      The recommended drug treatment for secondary prevention of myocardial infarction (MI) includes a combination of medications. These medications include a β-blocker, an angiotensin-converting enzyme (ACE) inhibitor, a statin, and dual antiplatelet treatment. Previously, statin treatment was only offered to patients with a cholesterol level of > 5 mmol/l. However, it has been shown that all patients with coronary heart disease benefit from a reduction in total cholesterol and LDL.

      β-blockers are estimated to prevent deaths by 12/1000 treated/year, while ACE inhibitors reduce deaths by 5/1000 treated in the first month post-MI. Trials have also shown reduced long-term mortality for all patients. Aspirin should be given indefinitely, and clopidogrel should be given for up to 12 months.

      In summary, the recommended drug treatment for secondary prevention of myocardial infarction includes a combination of medications that have been shown to reduce mortality rates. It is important for patients to continue taking these medications as prescribed by their healthcare provider.

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      • Cardiovascular Health
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  • Question 24 - A 50-year-old lady comes to the clinic with tortuous, dilated, superficial leg veins....

    Incorrect

    • A 50-year-old lady comes to the clinic with tortuous, dilated, superficial leg veins. These have been present for a few years and do not cause any discomfort, but she is unhappy with their appearance.

      Upon examination, there are no skin changes, leg ulcers, or signs of thrombophlebitis.

      What is the MOST SUITABLE NEXT step in management?

      Your Answer:

      Correct Answer: Aspirin 75 mg OD

      Explanation:

      Conservative Management of Varicose Veins

      Conservative management is recommended for patients with asymptomatic varicose veins, meaning those that are not causing pain, skin changes, or ulcers. This approach includes lifestyle changes such as weight loss, light/moderate physical activity, leg elevation, and avoiding prolonged standing. Compression stockings are also recommended to alleviate symptoms.

      There is no medication available for varicose veins, and ultrasound is not necessary in the absence of thrombosis. Referral to secondary care may be necessary based on local guidelines, particularly if the patient is experiencing discomfort, swelling, heaviness, or itching, or if skin changes such as eczema are present due to chronic venous insufficiency. Urgent referral is required for venous leg ulcers and superficial vein thrombosis.

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      • Cardiovascular Health
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  • Question 25 - A 72-year-old bus driver comes to you for consultation after undergoing an abdominal...

    Incorrect

    • A 72-year-old bus driver comes to you for consultation after undergoing an abdominal ultrasound scan as part of a routine health check. The scan reveals an abdominal aortic aneurysm (AAA) measuring 4 cm, and he has no symptoms.
      What is the most suitable course of action?

      Your Answer:

      Correct Answer: Refer for annual ultrasound surveillance

      Explanation:

      Recommended Actions for Patients with Abdominal Aortic Aneurysm

      Patients with an abdominal aortic aneurysm (AAA) require careful monitoring and appropriate actions to prevent complications. Here are some recommended actions based on the size of the AAA and the patient’s condition:

      Annual ultrasound surveillance: Asymptomatic patients with an AAA measuring 3.0–4.4 cm should undergo annual ultrasound monitoring to detect any changes in size or shape. This can help identify the need for further intervention, such as surgery or endovascular repair. In addition, patients should be advised to quit smoking, control their blood pressure, and take statins and antiplatelet therapy as needed.

      Refer for follow-up ultrasound in three months: If the AAA measures between 4.5 and 5.4 cm, a follow-up ultrasound should be arranged in three months to monitor any progression. This can help determine the optimal timing for intervention and prevent rupture or dissection.

      Advise the patient to inform the DVLA and cease driving: Patients who have an AAA and hold a Group 2 driving license must notify the Driver and Vehicle Licensing Agency (DVLA) and stop driving if the aneurysm diameter is larger than 5.5 cm. This is to ensure the safety of the patient and other road users.

      Arrange a repeat scan in one year: The recommended screening interval for AAA is determined by its size, with a maximum interval of one year. Therefore, patients with an AAA measuring more than 5.5 cm or with rapid growth should undergo repeat scans every six months to one year to monitor any changes.

      Monitor all patients with an AAA: Regardless of symptoms, all patients with an AAA measuring more than 3 cm require monitoring and appropriate actions to prevent complications. If the patient develops symptoms such as pain, they may need additional investigation and possible intervention to prevent rupture or dissection.

      By following these recommended actions, patients with an AAA can receive timely and appropriate care to prevent complications and improve their outcomes.

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      • Cardiovascular Health
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  • Question 26 - A 35-year-old man is referred by the practice nurse following a routine health...

    Incorrect

    • A 35-year-old man is referred by the practice nurse following a routine health check. He is a smoker with a strong family history of premature death from ischaemic heart disease. His fasting cholesterol concentration is 7.2 mmol/l and his estimated 10-year risk of a coronary heart disease event is >30%.
      Select from the list the single most suitable management option in this patient.

      Your Answer:

      Correct Answer: Statin

      Explanation:

      NICE recommends primary prevention for individuals under 84 years old who have a risk of over 10% of developing cardiovascular disease, which can be estimated using the QRISK2 assessment tool. To address modifiable risk factors, interventions such as dietary advice, smoking cessation support, alcohol moderation, and weight reduction should be offered. For lipid management, both non-pharmacological and pharmacological interventions should be utilized, with atorvastatin 20 mg being the recommended prescription for primary prevention. Lipids should be checked after 3 months, with the aim of reducing non-HDL cholesterol by over 40%. However, excessive drug usage in the elderly should be considered carefully by doctors, as cardiovascular risks exceeding 5-10% may be found in elderly men based on age and gender alone. NICE advises against routinely prescribing fibrates, bile acid sequestrants, nicotinic acid, omega-3 fatty acid compounds, or a combination of a statin and another lipid-modifying drug. First-line treatment for primary hyperlipidaemia is a statin, with other options such as bile acid sequestrants being considered if statins are contraindicated or not tolerated. For primary prevention of CVD, high-intensity statin treatment should be offered to individuals under 84 years old with an estimated 10-year risk of 10% or more using the QRISK assessment tool. Diet modification alone is not recommended for individuals with a risk score over 30%. Ezetimibe can be considered for individuals with primary hypercholesterolaemia if a statin is contraindicated or not tolerated, but it is not the first choice of drug in this scenario.

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      • Cardiovascular Health
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  • Question 27 - A 59-year-old man comes to your clinic with hypertension. His initial investigations, including...

    Incorrect

    • A 59-year-old man comes to your clinic with hypertension. His initial investigations, including blood tests, electrocardiogram, and urine dip, all come back normal. His QRisk2 score is 18%. His blood pressure readings are consistently above 150/100. He has no significant medical history, but there is a family history of high blood pressure. Despite making lifestyle changes, his blood pressure remains elevated, and you both agree on treatment.

      What is your plan for managing this patient?

      Your Answer:

      Correct Answer: Prescribe a calcium channel blocker

      Explanation:

      First Step in Managing Hypertension

      Having diagnosed hypertension, the first step in management involves considering several key factors in the patient’s history. One important factor is whether the patient has diabetes, as this influences the choice of antihypertensive medication. In diabetic patients, ACE inhibitors or ARBs are preferred over calcium antagonists due to their secondary benefits in managing diabetes.

      Another important factor is the patient’s age, with a threshold of 55 years indicating the preference for a calcium antagonist over an ACE inhibitor or ARB in step 1. This is because these medications are less effective in older individuals. Other age thresholds, such as 40 and 80 years, are also important in diagnosis and monitoring.

      While not relevant to this question, it is important to note that in patients under 80 years of age, the target blood pressure should be below 140/90 in clinic or below 135/85 in home or ambulatory monitoring. Additionally, a statin may be considered for patients with a QRisk2 score above 10.

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      • Cardiovascular Health
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  • Question 28 - A 72-year-old man visits his GP clinic with a history of hypertension. He...

    Incorrect

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

      Your Answer:

      Correct Answer: B-type natriuretic peptide

      Explanation:

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

      Diagnosis of Chronic Heart Failure

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

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

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

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

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      • Cardiovascular Health
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  • Question 29 - A 55-year-old carpenter comes to see you in surgery following an MI three...

    Incorrect

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

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

      Which one of the following foods should he avoid?

      Your Answer:

      Correct Answer: Pork

      Explanation:

      Tips for a Heart-Healthy Diet after a Heart Attack

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

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

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

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

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      • Cardiovascular Health
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  • Question 30 - A 72-year-old woman was recently diagnosed with atrial fibrillation during a routine pulse...

    Incorrect

    • A 72-year-old woman was recently diagnosed with atrial fibrillation during a routine pulse check. She has a medical history of fatty liver disease and well-managed hypertension, which is treated with amlodipine. Her weekly alcohol consumption is 14 units.

      Her blood test results are as follows:

      - Hb 110 g/L (115 - 160)
      - Creatinine 108 µmol/L (55 - 120)
      - Estimated GFR (eGFR) 57 mL/min/1.73 m² (>90)
      - ALT 50 u/L (3 - 40)

      To evaluate her bleeding risk before initiating anticoagulation therapy, her ORBIT score is computed.

      What factors would increase this patient's ORBIT score?

      Your Answer:

      Correct Answer:

      Explanation:

      The ORBIT score includes anaemia and renal impairment as factors that indicate a higher risk of bleeding in patients with atrial fibrillation who are receiving anticoagulation treatment. This scoring tool is now recommended by NICE guidelines for assessing bleeding risk. The ORBIT score consists of five parameters, including age (75+ years), anaemia (haemoglobin <130 g/L in males, <120 g/L in females), bleeding history, and renal impairment (eGFR <60 mL/min/1.73 m²). In this patient's case, her anaemia and renal function would meet the criteria for scoring. Age is not a relevant factor as she is under 75 years old. Alcohol intake is not a criterion used in the ORBIT score, and hypertension is not included in this scoring tool but would be considered in the CHA2DS2-VASc scoring tool for assessing stroke risk. 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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      • Cardiovascular Health
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SESSION STATS - PERFORMANCE PER SPECIALTY

Cardiovascular Health (7/10) 70%
Passmed