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  • Question 1 - A 67-year-old man presents with shortness of breath.
    An ECG shows atrial fibrillation (AF).
    He...

    Incorrect

    • 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: Warfarin

      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.

    • This question is part of the following fields:

      • Cardiovascular Health
      83.6
      Seconds
  • Question 2 - A 70-year-old man presents with exertional chest pain and a positive exercise tolerance...

    Incorrect

    • A 70-year-old man presents with exertional chest pain and a positive exercise tolerance test. He refuses to undergo an angiogram and is discharged with a medication regimen consisting of aspirin 75 mg od, simvastatin 40 mg on, atenolol 50 mg od, and a GTN spray prn. Upon examination, his pulse is 72 bpm and his blood pressure is 130/80 mmHg. During follow-up, he continues to frequently use his GTN spray. What is the most appropriate course of action for his management?

      Your Answer: Add nifedipine MR 30 mg od

      Correct Answer: Increase atenolol to 100 mg od

      Explanation:

      If a patient with angina doesn’t respond well to the first-line drug (such as a beta-blocker), the dose should be increased before adding another drug. The recommended dose of atenolol for angina is 100 mg daily, and a pulse rate of 72 bpm indicates inadequate beta-blockade. The starting dose of isosorbide mononitrate is 10 mg bd.

      Angina pectoris can be managed through lifestyle changes, medication, percutaneous coronary intervention, and surgery. In 2011, NICE released guidelines for the management of stable angina. Medication is an important aspect of treatment, and all patients should receive aspirin and a statin unless there are contraindications. Sublingual glyceryl trinitrate can be used to abort angina attacks. NICE recommends using either a beta-blocker or a calcium channel blocker as first-line treatment, depending on the patient’s comorbidities, contraindications, and preferences. If a calcium channel blocker is used as monotherapy, a rate-limiting one such as verapamil or diltiazem should be used. If used in combination with a beta-blocker, a longer-acting dihydropyridine calcium channel blocker like amlodipine or modified-release nifedipine should be used. Beta-blockers should not be prescribed concurrently with verapamil due to the risk of complete heart block. If initial treatment is ineffective, medication should be increased to the maximum tolerated dose. If a patient is still symptomatic after monotherapy with a beta-blocker, a calcium channel blocker can be added, and vice versa. If a patient cannot tolerate the addition of a calcium channel blocker or a beta-blocker, long-acting nitrate, ivabradine, nicorandil, or ranolazine can be considered. If a patient is taking both a beta-blocker and a calcium-channel blocker, a third drug should only be added while awaiting assessment for PCI or CABG.

      Nitrate tolerance is a common issue for patients who take nitrates, leading to reduced efficacy. NICE advises patients who take standard-release isosorbide mononitrate to use an asymmetric dosing interval to maintain a daily nitrate-free time of 10-14 hours to minimize the development of nitrate tolerance. However, this effect is not seen in patients who take once-daily modified-release isosorbide mononitrate.

    • This question is part of the following fields:

      • Cardiovascular Health
      195.6
      Seconds
  • Question 3 - A 27-year-old professional footballer collapses while playing football.

    He is rushed to the Emergency...

    Correct

    • A 27-year-old professional footballer collapses while playing football.

      He is rushed to the Emergency department, and is found to be in ventricular tachycardia. He is defibrillated successfully and his 12 lead ECG following resuscitation demonstrates left ventricular hypertrophy. Ventricular tachycardia recurs and despite prolonged resuscitation he dies.

      What is the most likely diagnosis?

      Your Answer: Hypertrophic cardiomyopathy

      Explanation:

      Hypertrophic Cardiomyopathy and its ECG Findings

      The sudden onset of arrhythmia in a young and previously healthy individual is often indicative of hypertrophic cardiomyopathy (HCM). It is important to screen relatives for this condition. The majority of patients with HCM have an abnormal resting ECG, which may show nonspecific changes such as left ventricular hypertrophy, ST changes, and T-wave inversion. Other possible ECG findings include right or left axis deviation, conduction abnormalities, sinus bradycardia with ectopic atrial rhythm, and atrial enlargement.

      Ambulatory ECG monitoring can reveal atrial and ventricular ectopics, sinus pauses, intermittent or variable atrioventricular block, and non-sustained arrhythmias. However, the ECG findings do not necessarily correlate with prognosis. Arrhythmias associated with HCM can include premature ventricular complexes, non-sustained ventricular tachycardia, and supraventricular tachyarrhythmias. Atrial fibrillation is also a common complication, occurring in approximately 20% of cases and increasing the risk of fatal cardiac failure.

      It is important to note that there is no history to suggest drug abuse, and aortic stenosis is rare in the absence of congenital or rheumatic heart disease. A myocardial infarction or massive pulmonary embolism would have distinct ECG changes that are not typically seen in HCM.

    • This question is part of the following fields:

      • Cardiovascular Health
      32.4
      Seconds
  • Question 4 - A 67-year-old woman presents to the emergency department with a 3-day history of...

    Incorrect

    • 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: Continue apixaban and repeat ultrasound in 7 days

      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

    • This question is part of the following fields:

      • Cardiovascular Health
      91.1
      Seconds
  • Question 5 - Which of the following calcium channel blockers is most likely to cause pulmonary...

    Correct

    • Which of the following calcium channel blockers is most likely to cause pulmonary edema in a patient with a history of chronic heart failure?

      Your Answer: Verapamil

      Explanation:

      Verapamil exhibits the strongest negative inotropic effect among calcium channel blockers.

      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.

    • This question is part of the following fields:

      • Cardiovascular Health
      11.9
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  • Question 6 - A 60-year-old man presents to his General Practitioner to discuss whether he requires...

    Incorrect

    • A 60-year-old man presents to his General Practitioner to discuss whether he requires a statin. His brother has encouraged him to book the appointment because ‘everyone in the family takes a statin’, due to familial hypercholesterolaemia. He has no significant medical history and rarely consults with a doctor. His total cholesterol is 8.2 mmol/l.
      What is the most appropriate management option?

      Your Answer: Commence Atorvastatin 20 mg for primary prevention of cardiovascular disease

      Correct Answer: Carry out blood tests for liver, renal and thyroid function, HbA1c and lipid panel

      Explanation:

      Management of Suspected Familial Hypercholesterolaemia

      Suspected familial hypercholesterolaemia requires a thorough diagnostic and management approach. The first step is to carry out blood tests for liver, renal, and thyroid function, HbA1c, and lipid panel. Additionally, a full cardiovascular assessment and exclusion of secondary causes of hypercholesterolaemia should be conducted before referral.

      QRisk2 scoring is not appropriate in suspected familial hypercholesterolaemia due to the high risk of premature heart disease associated with the condition. Atorvastatin 20 mg is a good choice for primary prevention, but further tests are necessary to establish its suitability for the patient. Atorvastatin 80 mg is often given as secondary prevention, but there is no evidence that this is necessary for the patient from the information provided.

      Referral to a lipid clinic in secondary care is imperative for patients with suspected familial hypercholesterolaemia. This condition should be suspected in adults with a total cholesterol >7.5mmol/l and/or a personal or family history of a cardiovascular event before the age of 60 years old. Basic blood tests will provide important diagnostic and management information, ruling out secondary causes of hypercholesterolaemia and assessing the patient’s suitability for treatment with lipid-lowering drugs.

    • This question is part of the following fields:

      • Cardiovascular Health
      69
      Seconds
  • Question 7 - A 72-year-old lady comes to her GP for a yearly check-up of her...

    Incorrect

    • A 72-year-old lady comes to her GP for a yearly check-up of her heart failure treatment.

      She has a blood pressure reading of 165/90 mmHg. At present, she is taking furosemide and aspirin, and she feels short of breath when walking uphill.

      What would be the best medication to include in her treatment plan?

      Your Answer:

      Correct Answer: Isosorbide mononitrate

      Explanation:

      First Line Treatments for Heart Failure

      ACE inhibitors and beta blockers are the primary medications used in the treatment of heart failure. The SOLVD and CONSENSUS trials have shown that ACE inhibitors are a cornerstone in the management of heart failure. It has been proven that higher doses of ACE inhibitors provide greater benefits. These medications are generally well-tolerated, particularly in mild cases. If ACE inhibitors are not well-tolerated, an ARB can be used as an alternative. Mineralocorticoid receptor antagonists are also recommended as a first-line treatment for heart failure.

    • This question is part of the following fields:

      • Cardiovascular Health
      0
      Seconds
  • Question 8 - A 49-year-old male with type 2 diabetes presents for review. He has a...

    Incorrect

    • A 49-year-old male with type 2 diabetes presents for review. He has a past medical history of hypertension, migraine, and obesity (BMI is 38). Currently, he takes metformin 1 g BD and ramipril 5 mg OD for blood pressure control. His latest HbA1c is 50 mmol/mol, and his total cholesterol is 5.2 with an LDL cholesterol of 3.5. His QRisk2 score is 21%.

      During the consultation, you discuss the addition of lipid-lowering medication to reduce his cardiovascular risk, especially in light of his recently treated hypertension. You both agree that starting him on Atorvastatin 20 mg at night is an appropriate treatment for primary prevention of cardiovascular disease.

      Before prescribing the medication, you review his latest blood results, which show normal full blood count, renal function, and thyroid function. However, his liver function tests reveal an ALT of 106 IU/L (<60) and an ALP of 169 IU/L (20-200). Bilirubin levels are within normal limits.

      Upon further investigation, you discover that the ALT rise has persisted since his first blood tests at the surgery over four years ago. However, the liver function results have remained stable over this time, showing no significant variation from the current values. A liver ultrasound done two years ago reports some evidence of fatty infiltration only.

      What is the most appropriate management strategy for this patient?

      Your Answer:

      Correct Answer: Atorvastatin 20 mg nocte can be initiated and repeat liver function tests should be performed within the first three months of use

      Explanation:

      Liver Function and Statin Therapy

      Liver function should be assessed before starting statin therapy. If liver transaminases are three times the upper limit of normal, statins should not be initiated. However, if the liver enzymes are elevated but less than three times the upper limit of normal, statin therapy can be used. It is important to repeat liver function tests within the first three months of treatment and then at 12 months, as well as if a dose increase is made or if clinically indicated.

      In the case of a modest ALT elevation due to fatty deposition in the liver, statin therapy can still be beneficial for primary prevention, especially if the patient’s Qrisk2 score is over 10%. Mild derangement in liver function is not uncommon in overweight type 2 diabetics. The patient can be treated with the usual NICE-guided primary prevention dose of atorvastatin, which is 20 mg nocte. A higher dose or alternative statin may be required in the future, depending on the patient’s response to the initial treatment and lifestyle modifications. The slight ALT rise doesn’t necessarily require a lower statin dose.

    • This question is part of the following fields:

      • Cardiovascular Health
      0
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  • Question 9 - A 35-year-old woman presents to her General Practitioner with a 3-year history of...

    Incorrect

    • A 35-year-old woman presents to her General Practitioner with a 3-year history of increasing dyspnoea with strenuous exercise. She has also had occasional chest pain on exertion.
      On examination, she has an ejection systolic murmur. Following an examination and electrocardiogram (ECG) in primary care, she is referred for a cardiology review and hypertrophic cardiomyopathy is diagnosed.
      Which of the following is the most appropriate screening method for her sister?

      Your Answer:

      Correct Answer: Echocardiography

      Explanation:

      Diagnosing Hypertrophic Cardiomyopathy: Methods and Limitations

      Hypertrophic cardiomyopathy (HCM) is a genetic heart condition that can lead to sudden death, especially in young athletes. Diagnosis of HCM is based on the demonstration of unexplained myocardial hypertrophy, which can be detected using two-dimensional echocardiography. However, the criteria for diagnosis vary depending on the patient’s size and family history. Genetic screening is not always reliable, as mutations are only found in 60% of patients. An abnormal electrocardiogram (ECG) is common but nonspecific, while exercise testing and ventilation-perfusion scans have limited diagnostic value. It is important to consider the limitations of these methods when evaluating patients with suspected HCM.

    • This question is part of the following fields:

      • Cardiovascular Health
      0
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  • Question 10 - A 65-year-old woman presents to the General Practitioner with intermittent cramp-like pain in...

    Incorrect

    • A 65-year-old woman presents to the General Practitioner with intermittent cramp-like pain in the buttock, thigh and calf. The symptoms are worse on walking and relieved by rest. She had a stent placed in her coronary artery three years ago. On examination, both legs are of normal colour, but the pedal pulses are difficult to palpate. Sensation is mildly reduced in the right foot.

      What is the most suitable course of action?

      Your Answer:

      Correct Answer: Measure ankle : brachial systolic pressure index

      Explanation:

      Understanding Intermittent Claudication: Diagnosis and Management

      Intermittent claudication is a common symptom of peripheral arterial disease. Patients typically experience pain or cramping in their legs during physical activity, which subsides with rest. An ankle-brachial pressure index (ABPI) of less than 0.9 supports the diagnosis, indicating reduced blood flow to the affected limb.

      The severity of arterial disease can be assessed using the ABPI, with values under 0.5 indicating severe disease. Exercise can improve walking distance, and patients should be encouraged to continue walking beyond the point of pain. Addressing any risk factors for cardiovascular disease is also important.

      Referral to a vascular surgeon may be necessary if symptoms are lifestyle limiting. Magnetic resonance angiography can be used to assess the extent of arterial disease prior to any revascularization procedure. Ultrasonography can help determine the site of disease in peripheral arterial disease.

      Bilateral symptoms may indicate neurogenic claudication due to spinal stenosis, which can be confirmed with an MRI scan. Sciatica is also a possible differential diagnosis, particularly if there are sensory changes in the foot. An MRI scan may be useful in such cases.

      Overall, understanding the diagnosis and management of intermittent claudication is crucial for effective treatment and improved quality of life for patients.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 11 - What are the primary indications for administering alpha blockers? ...

    Incorrect

    • What are the primary indications for administering alpha blockers?

      Your Answer:

      Correct Answer: Hypertension + benign prostatic hyperplasia

      Explanation:

      Understanding Alpha Blockers

      Alpha blockers are medications that are commonly prescribed for the treatment of benign prostatic hyperplasia and hypertension. These drugs work by blocking the alpha-adrenergic receptors in the body, which can help to relax the smooth muscles in the prostate gland and blood vessels, leading to improved urine flow and lower blood pressure. Some examples of alpha blockers include doxazosin and tamsulosin.

      While alpha blockers can be effective in managing these conditions, they can also cause side effects. Some of the most common side effects of alpha blockers include postural hypotension, drowsiness, dyspnea, and cough. Patients who are taking alpha blockers should be aware of these potential side effects and should speak with their healthcare provider if they experience any symptoms.

    • This question is part of the following fields:

      • Cardiovascular Health
      0
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  • Question 12 - Your patient, who has been discharged after a non-ST elevation myocardial infarction, is...

    Incorrect

    • Your patient, who has been discharged after a non-ST elevation myocardial infarction, is unsure if he has experienced a heart attack. Which statement from the list accurately describes non-ST elevation myocardial infarction?

      Your Answer:

      Correct Answer: There is a risk of recurrent infarction in up to 10% in the first month

      Explanation:

      Understanding Non-ST Elevation Myocardial Infarction (NSTEMI) and Unstable Angina

      Non-ST elevation myocardial infarction (NSTEMI) is a condition that is diagnosed in patients with chest pain who have elevated troponin T levels without the typical ECG changes of acute MI, such as Q-waves and ST elevation. Instead, there may be persistent or transient ST-segment depression or T-wave inversion, flat T waves, pseudo-normalisation of T waves, or no ECG changes at all. On the other hand, unstable angina is diagnosed when there is chest pain but no rise in troponin levels.

      Despite their differences, both NSTEMI and unstable angina are grouped together as acute coronary syndromes. In the acute phase, 5-10% of patients may experience death or re-infarction. Additionally, another 5-10% of patients may experience death due to recurrent myocardial infarction in the month after an acute episode.

      To manage these patients, many units take an aggressive approach with early angiography and angioplasty. By understanding the differences between NSTEMI and unstable angina, healthcare professionals can provide appropriate and timely treatment to improve patient outcomes.

    • This question is part of the following fields:

      • Cardiovascular Health
      0
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  • Question 13 - A 55-year-old man visits his General Practitioner after undergoing primary coronary angioplasty for...

    Incorrect

    • A 55-year-old man visits his General Practitioner after undergoing primary coronary angioplasty for a non-ST elevation myocardial infarction. He has been informed that he has a drug-eluting stent and is worried about potential negative consequences.
      What is accurate regarding these stents?

      Your Answer:

      Correct Answer: The risk of re-stenosis is reduced

      Explanation:

      Understanding Drug-Eluting Stents and Antiplatelet Therapy for Coronary Stents

      Drug-eluting stents (DESs) are metal stents coated with a growth-inhibiting agent that reduces the frequency of restenosis by about 50%. However, the reformation of endothelium is slowed, which prolongs the risk of thrombosis. DESs are recommended if the artery to be treated has a calibre < 3 mm or the lesion is longer than 15 mm, and the price difference between DESs and bare metal stents (BMSs) is no more than £300. Antiplatelet therapy with aspirin and clopidogrel is required for patients with coronary stents to reduce stent thrombosis. Aspirin is continued indefinitely, while clopidogrel should be used for at least one month with a BMS (ideally, up to one year), and for at least 12 months with a DES. It is important for cardiologists to explain this information to patients, but General Practitioners should also have some knowledge of these procedures. Understanding Drug-Eluting Stents and Antiplatelet Therapy for Coronary Stents

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 14 - A 65-year-old man with a history of depression and lumbar spinal stenosis presents...

    Incorrect

    • A 65-year-old man with a history of depression and lumbar spinal stenosis presents with a swollen and painful left calf. He is seen in the DVT clinic and found to have a raised D-dimer. As a result, he undergoes a Doppler scan which reveals a proximal deep vein thrombosis. Despite being active and otherwise healthy, the patient has not had any recent surgeries or prolonged periods of immobility. He is initiated on a direct oral anticoagulant.

      What is the appropriate duration of treatment for this patient?

      Your Answer:

      Correct Answer: 6 months

      Explanation:

      For provoked cases of venous thromboembolism, such as those following recent surgery, warfarin treatment is typically recommended for a duration of three months. However, for unprovoked cases, where the cause is unknown, a longer duration of six months is typically recommended.

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

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

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

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

    • This question is part of the following fields:

      • Cardiovascular Health
      0
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  • Question 15 - A 76-year-old woman presents for review. She underwent ambulatory blood pressure monitoring which...

    Incorrect

    • A 76-year-old woman presents for review. She underwent ambulatory blood pressure monitoring which revealed an average reading of 142/90 mmHg. Apart from hypothyroidism, there is no significant medical history. Her 10-year cardiovascular risk score is 23%. What is the best course of action for management?

      Your Answer:

      Correct Answer: Start amlodipine

      Explanation:

      For patients under 80 years old, the target blood pressure during clinic readings is 140/90 mmHg. However, the average reading is currently above this threshold, indicating the need for treatment with a calcium channel blocker.

      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
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  • Question 16 - You start a patient on atorvastatin after their cholesterol was found to be...

    Incorrect

    • You start a patient on atorvastatin after their cholesterol was found to be raised in the context of a QRISK of 15%. You repeat the blood tests 6 months after starting treatment.

      Which of the following blood results does NICE recommend using to determine the next course of action?

      Your Answer:

      Correct Answer: Non-HDL cholesterol

      Explanation:

      Monitoring Statin Treatment for Primary Prevention

      Following the initiation of statin treatment for primary prevention, it is recommended to have a repeat blood test after 3 months. The non-HDL cholesterol level should be interpreted to guide the next steps in management. The goal of treatment is to reduce non-HDL levels by 40% of the patient’s baseline. If adherence, timing of the dose, and lifestyle measures are in place, an increase in dose may be necessary.

      It is not routine to investigate creatine kinase in this context, but it would be helpful to investigate unexplained muscle symptoms. Liver function tests are not an option, but NICE advises testing these 3 months and 12 months following statin initiation. If stable, no further monitoring for LFTs is required after this.

    • This question is part of the following fields:

      • Cardiovascular Health
      0
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  • Question 17 - Which of the following statements about warfarin is accurate? ...

    Incorrect

    • Which of the following statements about warfarin is accurate?

      Your Answer:

      Correct Answer: Warfarin can be used when breastfeeding

      Explanation:

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

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

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

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

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

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      • Cardiovascular Health
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  • Question 18 - A 48-year-old man presents to your clinic with concerns about his risk of...

    Incorrect

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

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

      Your Answer:

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

      Explanation:

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

      Management of Hyperlipidaemia: NICE Guidelines

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

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 19 - 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
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  • Question 20 - A 63-year-old man presents with a three-month history of palpitation. He reports feeling...

    Incorrect

    • 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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      • Cardiovascular Health
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  • Question 21 - A 48-year-old man comes to your GP clinic complaining of feeling generally unwell...

    Incorrect

    • A 48-year-old man comes to your GP clinic complaining of feeling generally unwell and lethargic. His wife notes that he has been eating less than usual and gets tired easily. He has a history of hypertension but no other significant medical history. He drinks alcohol socially and has a stressful job as a banker, which led him to start smoking 15 cigarettes a day for the past 13 years. He believes that work stress is the cause of his symptoms and asks for a recommendation for a counselor to help him manage it. What should be the next step?

      Your Answer:

      Correct Answer: Refer for an urgent Chest X-Ray

      Explanation:

      If a person aged 40 or over has appetite loss and is a smoker, an urgent chest X-ray should be offered within two weeks, according to the updated 2015 NICE guidelines. This is because appetite loss is now considered a potential symptom of lung cancer. While counseling, smoking cessation, and a career change may be helpful, investigating the possibility of lung cancer is the most urgent action required. It is important to address each issue separately, as trying to tackle all three at once could be overwhelming for the patient.

      Referral Guidelines for Lung Cancer

      Lung cancer is a serious condition that requires prompt diagnosis and treatment. The 2015 NICE cancer referral guidelines provide clear advice on when to refer patients for suspected lung cancer. According to these guidelines, patients should be referred using a suspected cancer pathway referral for an appointment within 2 weeks if they have chest x-ray findings that suggest lung cancer or are aged 40 and over with unexplained haemoptysis.

      For patients aged 40 and over who have 2 or more unexplained symptoms such as cough, fatigue, shortness of breath, chest pain, weight loss, or appetite loss, an urgent chest x-ray should be offered within 2 weeks to assess for lung cancer. This recommendation also applies to patients who have ever smoked and have 1 or more of these unexplained symptoms.

      In addition, patients aged 40 and over with persistent or recurrent chest infection, finger clubbing, supraclavicular lymphadenopathy or persistent cervical lymphadenopathy, chest signs consistent with lung cancer, or thrombocytosis should be considered for an urgent chest x-ray within 2 weeks to assess for lung cancer.

      Overall, these guidelines provide clear and specific recommendations for healthcare professionals to identify and refer patients with suspected lung cancer for prompt diagnosis and treatment.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 22 - Which one of the following statements regarding calcium channel blockers is accurate? ...

    Incorrect

    • Which one of the following statements regarding calcium channel blockers is accurate?

      Your Answer:

      Correct Answer: Short-acting formulations of nifedipine should not be used for angina or hypertension

      Explanation:

      The BNF cautions that the use of short-acting versions of nifedipine can result in significant fluctuations in blood pressure and trigger reflex tachycardia.

      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 23 - A 46-year-old Caucasian man has consistently high blood pressure readings above 155/95 mmHg....

    Incorrect

    • A 46-year-old Caucasian man has consistently high blood pressure readings above 155/95 mmHg. Despite being asymptomatic, he doesn't regularly monitor his blood pressure at home. His cardiovascular exam and fundoscopy are unremarkable, and his 12-lead ECG doesn't indicate left ventricular hypertrophy. He is currently taking a combination of amlodipine, ramipril, indapamide, and spironolactone. What is the most appropriate next step in his treatment plan?

      Your Answer:

      Correct Answer: Add hydralazine

      Explanation:

      Seeking Expert Advice for Resistant Blood Pressure

      As per NICE guidelines, if a patient is already taking four antihypertensive medications and their blood pressure remains resistant, it is recommended to seek expert advice. This is because if the blood pressure remains uncontrolled even after taking the optimal or maximum tolerated doses of four drugs, it may indicate a need for further evaluation and management. Seeking expert advice can help in identifying any underlying causes of resistant hypertension and developing an effective treatment plan. Therefore, it is important to consult with a specialist if the blood pressure remains uncontrolled despite taking four antihypertensive medications.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 24 - An asymptomatic 63-year-old man is found to have an irregular pulse during a...

    Incorrect

    • An asymptomatic 63-year-old man is found to have an irregular pulse during a routine check-up. A 12-lead ECG confirms atrial fibrillation. His blood pressure is 130/80 mmHg and his heart rate is 106bpm. He is not taking any regular medications and his blood and urine tests are normal. The physician prescribes bisoprolol to manage his condition.

      What is the most appropriate next step in managing this patient's atrial fibrillation?

      Your Answer:

      Correct Answer: Do not offer anticoagulation

      Explanation:

      According to NICE guidelines, anticoagulation should be considered for individuals with a CHA2DS2-VASc score of 1 or greater for men and 2 or greater for women to assess stroke risk in atrial fibrillation. As the patient’s score is 1, anticoagulation is not currently indicated. However, this will need to be reassessed if the patient reaches the age of 65 or develops other criteria such as congestive heart failure, hypertension, diabetes mellitus, stroke/TIA, or vascular disease. Direct-acting oral anticoagulants are the first-line choice for anticoagulation in atrial fibrillation, unless contraindicated or not suitable. Low molecular weight heparin is not a suitable choice for anticoagulation in this case. Warfarin may be considered as a second-line option if anticoagulation is required but a direct oral anticoagulant is not suitable or tolerated.

      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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  • Question 25 - A 55-year-old man with Tourette's and poorly controlled type 2 diabetes presents to...

    Incorrect

    • A 55-year-old man with Tourette's and poorly controlled type 2 diabetes presents to you with concerns about intermittent chest pain on exertion. He drinks 21 units of alcohol per week and smokes 20 cigarettes a day. His father died of a myocardial infarction at the age of 56 years. You refer him for suspected angina, provide advice on what to do if he experiences chest pain, and prescribe a GTN spray for use as needed. While prescribing the GTN spray, you notice a medication on his prescription list that he should avoid taking while being investigated for chest pain or using the GTN spray. What medication is this referring to?

      Your Answer:

      Correct Answer: Sildenafil

      Explanation:

      Sildenafil, a type of PDE 5 inhibitor, should not be used together with nitrates and nicorandil due to potential risks of significant hypotension and myocardial infarction. On the other hand, there are no known interactions between nitrates and metformin, gliclazide, sitagliptin, or atorvastatin according to the BNF.

      Phosphodiesterase type V inhibitors are medications used to treat erectile dysfunction and pulmonary hypertension. They work by increasing cGMP, which leads to relaxation of smooth muscles in blood vessels supplying the corpus cavernosum. The most well-known PDE5 inhibitor is sildenafil, also known as Viagra, which is taken about an hour before sexual activity. Other examples include tadalafil (Cialis) and vardenafil (Levitra), which have longer-lasting effects and can be taken regularly. However, these medications have contraindications, such as not being safe for patients taking nitrates or those with hypotension. They can also cause side effects such as visual disturbances, blue discolouration, and headaches. It is important to consult with a healthcare provider before taking PDE5 inhibitors.

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      • Cardiovascular Health
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  • Question 26 - A 67-year-old man presents for follow-up. He has a medical history of small...

    Incorrect

    • A 67-year-old man presents for follow-up. He has a medical history of small cell lung cancer and ischemic heart disease. His cancer was detected five months ago and he recently finished a round of chemotherapy. In terms of his heart health, he experienced a heart attack two years ago and underwent primary angioplasty with stent placement. He has not had any angina since then.

      Over the past week, he has been experiencing increasing shortness of breath, particularly at night, and has an occasional non-productive cough. He has also noticed that his wedding ring feels tight. Upon examination, his chest appears normal, but he does have distended neck veins and periorbital edema. What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Superior vena cava obstruction

      Explanation:

      Understanding Superior Vena Cava Obstruction

      Superior vena cava obstruction is a medical emergency that occurs when the superior vena cava, a large vein that carries blood from the upper body to the heart, is compressed. This condition is commonly associated with lung cancer, but it can also be caused by other malignancies, aortic aneurysm, mediastinal fibrosis, goitre, and SVC thrombosis. The most common symptom of SVC obstruction is dyspnoea, but patients may also experience swelling of the face, neck, and arms, headache, visual disturbance, and pulseless jugular venous distension.

      The management of SVC obstruction depends on the underlying cause and the patient’s individual circumstances. Endovascular stenting is often the preferred treatment to relieve symptoms, but certain malignancies may require radical chemotherapy or chemo-radiotherapy instead. Glucocorticoids may also be given, although the evidence supporting their use is weak. It is important to seek advice from an oncology team to determine the best course of action for each patient.

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      • Cardiovascular Health
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  • Question 27 - A 14-year-old girl comes to the clinic complaining of repeated episodes of collapsing....

    Incorrect

    • A 14-year-old girl comes to the clinic complaining of repeated episodes of collapsing. She reports that these episodes happen suddenly while she is playing sports. The patient has no significant medical history or family history. During the physical examination, an ejection systolic murmur is detected. Her blood pressure is 106/70 mmHg, and her pulse is 78 beats per minute. What is the probable cause of her symptoms?

      Your Answer:

      Correct Answer: Hypertrophic obstructive cardiomyopathy

      Explanation:

      Hypertrophic obstructive cardiomyopathy is a more frequent cause of sudden death or unexpected collapse in young individuals compared to aortic stenosis.

      Hypertrophic obstructive cardiomyopathy (HOCM) is a genetic disorder that affects muscle tissue and is inherited in an autosomal dominant manner. It is caused by mutations in genes that encode contractile proteins, with the most common defects involving the β-myosin heavy chain protein or myosin-binding protein C. HOCM is characterized by left ventricle hypertrophy, which leads to decreased compliance and cardiac output, resulting in predominantly diastolic dysfunction. Biopsy findings show myofibrillar hypertrophy with disorganized myocytes and fibrosis. HOCM is often asymptomatic, but exertional dyspnea, angina, syncope, and sudden death can occur. Jerky pulse, systolic murmurs, and double apex beat are also common features. HOCM is associated with Friedreich’s ataxia and Wolff-Parkinson White. ECG findings include left ventricular hypertrophy, nonspecific ST segment and T-wave abnormalities, and deep Q waves. Atrial fibrillation may occasionally be seen.

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      • Cardiovascular Health
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  • Question 28 - During his annual health review, a 67-year-old man with type 2 diabetes, hypercholesterolaemia,...

    Incorrect

    • 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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      • Cardiovascular Health
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  • Question 29 - A 73-year-old man who underwent bioprosthetic aortic valve replacement three years ago is...

    Incorrect

    • 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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      • Cardiovascular Health
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  • Question 30 - 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

    • This question is part of the following fields:

      • Cardiovascular Health
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SESSION STATS - PERFORMANCE PER SPECIALTY

Cardiovascular Health (2/6) 33%
Passmed