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  • Question 1 - A 56-year-old man presents with a racing heart. He states that this started...

    Incorrect

    • A 56-year-old man presents with a racing heart. He states that this started while he was mowing the lawn but subsided after he drank a glass of cold lemonade. However, his symptoms have returned. On physical examination, his pulse is regular and measures 150 bpm. An ECG reveals a narrow complex tachycardia with P waves linked to each QRS complex.
      What is the probable diagnosis? Choose ONE answer only.

      Your Answer: Ventricular tachycardia

      Correct Answer: Atrioventricular (AV) nodal re-entrant tachycardia

      Explanation:

      Differentiating AV Nodal Re-entrant Tachycardia from Other Arrhythmias: An ECG Analysis

      AV nodal re-entrant tachycardia is a type of arrhythmia that causes recurrent palpitations lasting for minutes to hours. Patients may also experience chest pain, shortness of breath, and syncope. The heart rate is usually between 150-250 bpm, and the rhythm is regular with narrow QRS complexes. Vagal manoeuvres can terminate the episode. However, it is essential to differentiate AV nodal re-entrant tachycardia from other arrhythmias, such as atrial fibrillation, atrial flutter, torsades de pointes, and ventricular tachycardia. An ECG analysis can help in this regard.

      Atrial fibrillation is characterised by irregular ventricular complexes with an absence of P waves. In contrast, atrial flutter shows a saw-tooth pattern with the absence of P waves. Torsades de pointes is a rare form of polymorphic ventricular tachycardia that causes a gradual change in the amplitude and twisting of the QRS complexes around the isoelectric line. It is associated with a prolonged QT interval. Ventricular tachycardia, on the other hand, is characterised by broad complexes on ECG.

      In conclusion, an ECG analysis is crucial in differentiating AV nodal re-entrant tachycardia from other arrhythmias. It helps in providing accurate diagnosis and appropriate treatment to the patients.

    • This question is part of the following fields:

      • Cardiovascular Health
      61.6
      Seconds
  • Question 2 - A 67-year old man with hypertension visited his general practitioner after an ambulatory...

    Correct

    • 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: 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
      20
      Seconds
  • Question 3 - 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: Chronic exertional compartment syndrome

      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.

    • This question is part of the following fields:

      • Cardiovascular Health
      19.6
      Seconds
  • Question 4 - A patient who started taking simvastatin half a year ago is experiencing muscle...

    Incorrect

    • A patient who started taking simvastatin half a year ago is experiencing muscle aches all over. What is not considered a risk factor for myopathy caused by statins?

      Your Answer: Female gender

      Correct Answer: Large fall in LDL-cholesterol

      Explanation:

      Statins are drugs that inhibit the action of HMG-CoA reductase, which is the enzyme responsible for cholesterol synthesis in the liver. However, they can cause adverse effects such as myopathy, liver impairment, and an increased risk of intracerebral hemorrhage in patients with a history of stroke. Statins should not be taken during pregnancy or in combination with macrolides. NICE recommends statins for patients with established cardiovascular disease, a 10-year cardiovascular risk of 10% or higher, type 2 diabetes mellitus, or type 1 diabetes mellitus with certain criteria. It is recommended to take statins at night, especially simvastatin, which has a shorter half-life than other statins. NICE recommends atorvastatin 20 mg for primary prevention and atorvastatin 80 mg for secondary prevention.

    • This question is part of the following fields:

      • Cardiovascular Health
      116
      Seconds
  • Question 5 - As a GP, what tests should be performed for an 80-year-old man with...

    Incorrect

    • As a GP, what tests should be performed for an 80-year-old man with a history of atrial fibrillation who has been started on amiodarone?

      Your Answer: CXR, TFTS, LFTS every 6 months

      Correct Answer: TFTs, LFTs every 6 months

      Explanation:

      Amiodarone, a class III antiarrhythmic drug, has the potential to impact various bodily systems such as the thyroid, liver, and lungs.

      To ensure patient safety, it is recommended to conduct liver and thyroid function tests every six months. Before initiating amiodarone treatment, a chest x-ray is necessary, but it is not required routinely after treatment unless respiratory symptoms arise.

      Adverse Effects and Drug Interactions of Amiodarone

      Amiodarone is a medication used to treat irregular heartbeats. However, its use can lead to several adverse effects. One of the most common adverse effects is thyroid dysfunction, which can manifest as either hypothyroidism or hyperthyroidism. Other adverse effects include corneal deposits, pulmonary fibrosis or pneumonitis, liver fibrosis or hepatitis, peripheral neuropathy, myopathy, photosensitivity, a slate-grey appearance, thrombophlebitis, injection site reactions, bradycardia, and lengthening of the QT interval.

      It is also important to note that amiodarone can interact with other medications. For example, it can decrease the metabolism of warfarin, leading to an increased INR. Additionally, it can increase digoxin levels. Therefore, it is crucial to monitor patients closely for adverse effects and drug interactions when using amiodarone. Proper management and monitoring can help minimize the risks associated with this medication.

    • This question is part of the following fields:

      • Cardiovascular Health
      16.8
      Seconds
  • Question 6 - A 65-year-old female with no prior medical history presents with a left-sided hemiparesis...

    Incorrect

    • A 65-year-old female with no prior medical history presents with a left-sided hemiparesis and is found to be in atrial fibrillation. Imaging reveals a cerebral infarction. What anticoagulation approach would be most suitable for this patient?

      Your Answer: 6 months of warfarin, started immediately

      Correct Answer: Aspirin started immediately switching to Lifelong warfarin after 2 weeks

      Explanation:

      Managing Atrial Fibrillation Post-Stroke

      Atrial fibrillation is a major risk factor for ischaemic stroke, making it crucial to identify and treat the condition in patients who have suffered a stroke or transient ischaemic attack (TIA). However, before starting any anticoagulation or antiplatelet therapy, it is important to rule out haemorrhage. For long-term stroke prevention, NICE Clinical Knowledge Summaries recommend warfarin or a direct thrombin or factor Xa inhibitor. The timing of when to start treatment depends on whether it is a TIA or stroke. In the case of a TIA, anticoagulation for AF should begin immediately after imaging has excluded haemorrhage. For acute stroke patients, anticoagulation therapy should be initiated after two weeks in the absence of haemorrhage. Antiplatelet therapy should be given during the intervening period. However, if imaging shows a very large cerebral infarction, the initiation of anticoagulation should be delayed.

    • This question is part of the following fields:

      • Cardiovascular Health
      72.7
      Seconds
  • Question 7 - During a late-night shift at an urgent care centre, you encounter a 30-year-old...

    Correct

    • 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: 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

    • This question is part of the following fields:

      • Cardiovascular Health
      81.2
      Seconds
  • Question 8 - A 78-year-old man is being evaluated for his hypertension. He has been taking...

    Correct

    • A 78-year-old man is being evaluated for his hypertension. He has been taking bendroflumethiazide 2.5mg od for the past 8 years. His current blood pressure is 152/96 mmHg. Upon clinical examination, no significant findings were noted. An echocardiogram from three months ago revealed an ejection fraction of 40% and mild left ventricular hypertrophy. What is the best course of action for managing this patient's condition?

      Your Answer: Add ramipril 1.25 mg od

      Explanation:

      The echocardiogram indicates that there is some level of left ventricular dysfunction. To manage this condition, it is crucial to initiate treatment with an ACE inhibitor. This medication will not only regulate the patient’s blood pressure but also decelerate the decline in her heart’s performance. Additionally, a beta-blocker is recommended as there is evidence of heart failure.

      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
      90.9
      Seconds
  • Question 9 - A 52-year-old heavy smoker with a long history of self-neglect presents to his...

    Correct

    • A 52-year-old heavy smoker with a long history of self-neglect presents to his GP with severe leg pain. On examination there are several, small punched-out ulcers situated on the lower third of both legs. Both dorsalis pedis and posterior tibial pulses appear absent.
      Select from the list the single most likely diagnosis.

      Your Answer: Multiple arterial ulcers

      Explanation:

      Arterial Ulceration in Smokers: Symptoms and Treatment Options

      Arterial ulceration is a common problem among smokers, which is characterized by intense leg pain and sleep interference. The absence of foot pulses bilaterally indicates peripheral vascular disease, and it is important to assess for ischaemic heart disease and carotid disease as well. Angioplasty or bypass surgery may be appropriate for improving the peripheral blood supply in a limited number of cases only, while peripheral vasodilators are rarely effective. However, other options such as varicose veins, vasculitis, injury, or bites should be ruled out before making a diagnosis. In this article, we will discuss the symptoms and treatment options for arterial ulceration in smokers.

    • This question is part of the following fields:

      • Cardiovascular Health
      39.4
      Seconds
  • Question 10 - A 68-year-old woman with a history of atrial fibrillation presents for a follow-up...

    Incorrect

    • A 68-year-old woman with a history of atrial fibrillation presents for a follow-up appointment. She recently experienced a transient ischemic attack and is currently taking bendroflumethiazide for hypertension. Her blood pressure at the appointment is 130/80 mmHg. As you discuss management options to decrease her risk of future strokes, what is her CHA2DS2-VASc score?

      Your Answer: 2

      Correct Answer: 4

      Explanation:

      Atrial fibrillation (AF) is a condition that requires careful management, including the use of anticoagulation therapy. The latest guidelines from NICE recommend assessing the need for anticoagulation in all patients with a history of AF, regardless of whether they are currently experiencing symptoms. The CHA2DS2-VASc scoring system is used to determine the most appropriate anticoagulation strategy, with a score of 2 or more indicating the need for anticoagulation. However, it is important to ensure a transthoracic echocardiogram has been done to exclude valvular heart disease, which is an absolute indication for anticoagulation.

      When considering anticoagulation therapy, doctors must also assess the patient’s bleeding risk. NICE recommends using the ORBIT scoring system to formalize this risk assessment, taking into account factors such as haemoglobin levels, age, bleeding history, renal impairment, and treatment with antiplatelet agents. While there are no formal rules on how to act on the ORBIT score, individual patient factors should be considered. The risk of bleeding increases with a higher ORBIT score, with a score of 4-7 indicating a high risk of bleeding.

      For many years, warfarin was the anticoagulant of choice for AF. However, the development of direct oral anticoagulants (DOACs) has changed this. DOACs have the advantage of not requiring regular blood tests to check the INR and are now recommended as the first-line anticoagulant for patients with AF. The recommended DOACs for reducing stroke risk in AF are apixaban, dabigatran, edoxaban, and rivaroxaban. Warfarin is now used second-line, in patients where a DOAC is contraindicated or not tolerated. Aspirin is not recommended for reducing stroke risk in patients with AF.

    • This question is part of the following fields:

      • Cardiovascular Health
      55.5
      Seconds
  • Question 11 - A 60-year-old man is known to have high blood pressure.
    Choose from the options...

    Correct

    • A 60-year-old man is known to have high blood pressure.
      Choose from the options the one drug that is expected to increase his blood pressure even more.

      Your Answer: Diclofenac

      Explanation:

      Certain medications and substances can cause an increase in blood pressure, known as drug-induced hypertension. Non-steroidal anti-inflammatory drugs (NSAIDs) and COX-2 selective agents cause sodium and water retention, leading to elevated blood pressure. Sympathomimetic amines, such as amphetamines and pseudoephedrine, can also have this effect. Corticosteroids, particularly those with strong mineralocorticoid effects, can cause fluid retention and hypertension. Oral contraceptives may slightly raise blood pressure in some women. Venlafaxine increases levels of norepinephrine, contributing to hypertension. Cyclosporine and tacrolimus, used in transplant and autoimmune patients, can also have a significant effect on blood pressure. Caffeine and certain dietary supplements, such as ginseng, natural liquorice, and yohimbine, can also cause drug-induced hypertension.

    • This question is part of the following fields:

      • Cardiovascular Health
      14.5
      Seconds
  • Question 12 - In what scenario would it be suitable to conduct 24-hour ambulatory blood pressure...

    Incorrect

    • In what scenario would it be suitable to conduct 24-hour ambulatory blood pressure monitoring?

      Your Answer: To confirm compliance with medication

      Correct Answer: In patients with resistant hypertension despite medication

      Explanation:

      When to Consider 24-Hour Ambulatory Blood Pressure Recording

      Patients with persistently raised blood pressure readings or borderline hypertension, resistant hypertension, suspected white-coat hypertension, variable blood pressure, suspected pregnancy-associated hypertension, or suspected hypotension should be considered for 24-hour ambulatory blood pressure recording. However, this method should not be used in suspected pre-eclampsia or palpitations. Suspected orthostatic hypotension should be investigated with tilt-table tests, while palpitations should be investigated with a 24-hour ECG.

    • This question is part of the following fields:

      • Cardiovascular Health
      57.9
      Seconds
  • Question 13 - A 35-year-old woman visits her doctor for a check-up. She is worried about...

    Correct

    • A 35-year-old woman visits her doctor for a check-up. She is worried about her risk of developing cardiovascular disease after hearing about a family member's recent diagnosis.
      Which of the following factors would most significantly increase her risk of cardiovascular disease?

      Your Answer: Rheumatoid arthritis

      Explanation:

      Patients with rheumatoid arthritis may have an increased risk of developing accelerated atherosclerosis, which is believed to be linked to the inflammatory process. The QRisk2 calculator, used to predict the 10-year risk of developing cardiovascular disease, includes rheumatoid arthritis as a risk factor. However, a blood pressure reading of 130/80 mmHg and a BMI of 24 kg/m2 are within the normal range and not a cause for concern. Additionally, the HbA1c level of 41 mmol/mol is normal and doesn’t indicate an increased risk of diabetes. While a family history of myocardial infarction is significant, it is only considered a risk factor if the relative was diagnosed before the age of 60, not at 65.

    • This question is part of the following fields:

      • Cardiovascular Health
      19.9
      Seconds
  • Question 14 - A 65-year-old lady is on warfarin for stroke prevention in atrial fibrillation. She...

    Incorrect

    • A 65-year-old lady is on warfarin for stroke prevention in atrial fibrillation. She comes in with a significantly elevated INR. Which of the following drugs is the most probable cause?

      Your Answer: St John's wort

      Correct Answer: Ciprofloxacin

      Explanation:

      Drug Interactions with Warfarin

      Ciprofloxacin, a cytochrome p450 inhibitor, can prolong the half-life of warfarin and increase the international normalized ratio (INR). However, the reaction is not always predictable, and susceptibility may be influenced by factors such as fever, infection, or malnutrition. While aspirin is known to increase the risk of bleeding due to its antiplatelet activity, it doesn’t have a clear relationship with INR.

      Drugs that are metabolized in the liver can induce hepatic microsomal enzymes, which can increase the rate of metabolism of another drug, resulting in lower plasma concentrations and a reduced effect. St. John’s wort is an enzyme inducer and can increase the metabolism of warfarin, making it less effective. It is important to be aware of potential drug interactions with warfarin to ensure its effectiveness and prevent adverse effects.

    • This question is part of the following fields:

      • Cardiovascular Health
      13.2
      Seconds
  • Question 15 - You assess a 52-year-old patient with hypertension who has been taking 2.5mg of...

    Correct

    • You assess a 52-year-old patient with hypertension who has been taking 2.5mg of ramipril for a month. He reports experiencing a persistent tickly cough that is causing him to lose sleep at night. Despite this, his blood pressure is now under control.

      What recommendations would you provide to him?

      Your Answer: Stop the ramipril and prescribe candesartan

      Explanation:

      When patients are unable to tolerate ACE inhibitors due to the common side effect of a dry, persistent cough, angiotensin-receptor blockers (ARBs) should be considered as an alternative. For individuals under the age of 55 who experience intolerance to ACE inhibitors, prescribing medications such as candesartan, an ARB, may be the next appropriate step.

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

      Lifestyle changes are also important in managing hypertension. Patients should aim for a low salt diet, reduce caffeine intake, stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more, and lose weight.

      Treatment for hypertension depends on the patient’s blood pressure classification. For stage 1 hypertension with ABPM/HBPM readings of 135/85 mmHg or higher, treatment is recommended for patients under 80 years old with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For stage 2 hypertension with ABPM/HBPM readings of 150/95 mmHg or higher, drug treatment is recommended regardless of age.

      The first-line treatment for patients under 55 years old or with a background of type 2 diabetes mellitus is an ACE inhibitor or angiotensin receptor blocker. Calcium channel blockers are recommended for patients over 55 years old or of black African or African-Caribbean origin. If a patient is already taking an ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker or thiazide-like diuretic can be added.

      If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, NICE recommends seeking expert advice or adding a fourth drug. Blood pressure targets vary depending on age, with a target of 140/90 mmHg for patients under 80 years old and 150/90 mmHg for patients over 80 years old. Direct renin inhibitors, such as Aliskiren, may be used in patients who are intolerant of other antihypertensive drugs, but their role is currently limited.

    • This question is part of the following fields:

      • Cardiovascular Health
      16.7
      Seconds
  • Question 16 - Which statement accurately describes chest pain? ...

    Correct

    • Which statement accurately describes chest pain?

      Your Answer: Pleuritic pain is sharp and localised and aggravated by coughing

      Explanation:

      Pain and Innervation in the Diaphragm, Lungs, and Pericardium

      The diaphragm is innervated by the phrenic nerve, which only supplies the central portion of the muscle. Therefore, pain originating in the outer diaphragm will not be referred to the tip of the shoulder. Additionally, the lung parenchyma and visceral pleura are insensitive to pain, meaning that any discomfort felt in these areas is likely due to surrounding structures.

      Pericarditis, inflammation of the pericardium surrounding the heart, can cause chest pain. However, this pain is typically relieved by sitting forward. This is because the pericardium is attached to the diaphragm and sternum, and sitting forward can reduce pressure on these structures, alleviating the pain. Understanding the innervation and sensitivity of these structures can aid in the diagnosis and management of chest pain.

    • This question is part of the following fields:

      • Cardiovascular Health
      77.5
      Seconds
  • Question 17 - You are speaking with a 57-year-old man who is worried about his blood...

    Correct

    • You are speaking with a 57-year-old man who is worried about his blood pressure control. He has been monitoring his blood pressure at home daily for the past week and consistently reads over 140/90 mmHg, with the highest reading being 154/86 mmHg. He has no chest symptoms and is otherwise healthy. He has a history of hypertension and is currently taking perindopril. He previously took amlodipine, but it was discontinued due to significant ankle edema. His recent blood test results are as follows:

      Na+ 136 mmol/L (135 - 145)
      K+ 4.6 mmol/L (3.5 - 5.0)
      Bicarbonate 24 mmol/L (22 - 29)
      Urea 5.1 mmol/L (2.0 - 7.0)
      Creatinine 80 µmol/L (55 - 120)

      What is the most appropriate next step in managing his hypertension?

      Your Answer: Thiazide-like diuretic

      Explanation:

      To improve control of poorly managed hypertension in a patient already taking an ACE inhibitor, the recommended step 2 treatment is to add either a calcium channel blocker or a thiazide-like diuretic. In this case, the preferred choice is a thiazide-like diuretic as the patient has a history of intolerance to calcium channel blockers. Aldosterone antagonist and beta-blocker are not appropriate choices for step 2 management. It is important to note that combining an ACE inhibitor with an angiotensin receptor blocker is not recommended due to the risk of acute kidney injury.

      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
      44.8
      Seconds
  • Question 18 - A 60-year-old man presents with congestive heart failure.
    Which of the following drugs may...

    Incorrect

    • A 60-year-old man presents with congestive heart failure.
      Which of the following drugs may be effective in reducing mortality?

      Your Answer: Aspirin

      Correct Answer: Enalapril

      Explanation:

      Pharmaceutical Treatments for Heart Failure: A Summary

      Heart failure is a serious condition that requires careful management. There are several pharmaceutical treatments available, each with its own benefits and limitations. Here is a summary of some of the most commonly used drugs:

      Enalapril: This drug blocks the conversion of angiotensin I to angiotensin II, leading to improved cardiac output and reduced hospitalization rates.

      Digoxin: While this drug doesn’t improve mortality rates, it can be useful in managing symptoms.

      Amlodipine: This drug has not been shown to improve survival rates, but may be used in conjunction with other medications.

      Aspirin: This drug is only useful in cases of coronary occlusion or myocardial infarction.

      Furosemide: This drug can relieve congestive symptoms, but is not relevant for all heart failure patients.

      It is important to work closely with a healthcare provider to determine the best course of treatment for each individual case of heart failure.

    • This question is part of the following fields:

      • Cardiovascular Health
      25.5
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  • Question 19 - A 59-year-old male is referred to you from the practice nurse after an...

    Incorrect

    • A 59-year-old male is referred to you from the practice nurse after an ECG shows he is in atrial fibrillation.

      When you take a history from him he complains of palpitations and he has also noticed some weight loss over the last two months. On examination, he has an irregularly irregular pulse and displays a fine tremor.

      What is the next most appropriate investigation to perform?

      Your Answer: Echocardiogram

      Correct Answer: Exercise tolerance test

      Explanation:

      Assessing Patients with Atrial Fibrillation

      When assessing patients with atrial fibrillation, it is crucial to identify any underlying causes. While some cases may be classified as lone AF, addressing any precipitating factors is the first step in treatment. Hyperthyroidism is a common cause of atrial fibrillation, and checking thyroid function tests is the next appropriate step in diagnosis. Other common causes include heart failure, myocardial infarction/ischemia, mitral valve disease, pneumonia, and alcoholism. Rarer causes include pericarditis, endocarditis, cardiomyopathy, sarcoidosis, and hemochromatosis.

      For paroxysmal arrhythmias, a 24-hour ECG can be useful, but in cases of persistent atrial fibrillation, an ECG is not necessary. Exercise tolerance tests are used to investigate and risk-stratify patients with cardiac chest pain. While an echocardiogram is useful in patients with atrial fibrillation to look for valve disease and other structural abnormalities, it is not the next most appropriate investigation in this case. Overall, identifying the underlying cause of atrial fibrillation is crucial in determining the appropriate treatment plan.

    • This question is part of the following fields:

      • Cardiovascular Health
      8
      Seconds
  • Question 20 - What are the primary indications for administering alpha blockers? ...

    Incorrect

    • What are the primary indications for administering alpha blockers?

      Your Answer: Hypertension + heart failure

      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
      29.4
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  • Question 21 - A 45-year-old man presents with complaints of dyspnea.

    On auscultation, you detect a...

    Correct

    • A 45-year-old man presents with complaints of dyspnea.

      On auscultation, you detect a systolic crescendo-decrescendo murmur that is most audible at the right upper sternal border. The murmur is loudest during expiration and decreases in intensity when the patient stands. The second heart sound is faint. The apex beat is forceful but not displaced.

      What is the probable diagnosis?

      Your Answer: Aortic sclerosis

      Explanation:

      Aortic Stenosis: Symptoms and Signs

      Aortic stenosis is a condition characterized by the narrowing of the aortic valve, which can lead to reduced blood flow from the heart to the rest of the body. One of the typical features of aortic stenosis is a systolic crescendo-decrescendo murmur that is loudest at the right upper sternal border. This murmur is usually heard during expiration and becomes softer when the patient stands. Additionally, the second heart sound is typically soft, and the apex beat is thrusting but not displaced.

      To summarize, aortic stenosis can be identified by a combination of symptoms and signs, including a specific type of murmur, a soft second heart sound, and a thrusting apex beat.

    • This question is part of the following fields:

      • Cardiovascular Health
      46.4
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  • Question 22 - A 75-year-old man with a history of angina, well-controlled on a combination of...

    Incorrect

    • A 75-year-old man with a history of angina, well-controlled on a combination of aspirin 75 mg, atenolol 50 mg od, simvastatin 40 mg od, and isosorbide mononitrate 20 mg bd, presents with a pulse rate of 70 bpm and blood pressure of 134/84 mmHg. He also has type II diabetes mellitus, managed with metformin. What is the most effective medication that should be prescribed for optimal secondary prevention?

      Your Answer:

      Correct Answer: Perindopril

      Explanation:

      Medication Options for Angina and Hypertension

      The National Institute for Health and Care Excellence (NICE) recommends considering treatment with an angiotensin-converting enzyme (ACE) inhibitor for secondary prevention in patients with stable angina and diabetes mellitus, as long as there are no contraindications. This should also be prescribed where there is co-existing hypertension, left ventricular dysfunction, chronic kidney disease, or previous myocardial infarction (MI).

      Amlodipine is a calcium-channel blocker which could be added to control hypertension; however, this patient’s blood pressure is normal on current therapy.

      Diltiazem is a non-dihydropyridine calcium-channel blocker which can be used as an alternative first-line treatment in angina. This patient is already on atenolol and is well controlled.

      Doxazosin is an alpha-blocker used in the management of hypertension. This patient’s blood pressure is within normal limits, so it is not currently indicated.

      Nicorandil is an anti-anginal medication due to its vasodilatory properties which can be added or used as a monotherapy when symptoms of angina are not controlled with a beta-blocker or calcium-channel blocker or these are not tolerated. This patient’s symptoms are controlled on atenolol, so nicorandil is not indicated.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 23 - A 55-year-old man is concerned about experiencing palpitations. He reports that they occur...

    Incorrect

    • A 55-year-old man is concerned about experiencing palpitations. He reports that they occur twice a day and are fast and irregular, with a possible association with alcohol consumption. He denies any chest pain or fainting episodes. On examination, his cardiovascular symptoms are normal, with a pulse of 72/min and a blood pressure of 116/78 mmHg. Blood tests and a 12-lead ECG are unremarkable. What would be the most suitable course of action for managing this patient's condition?

      Your Answer:

      Correct Answer: Arrange a Holter monitor

      Explanation:

      If a patient experiences palpitations, the first step in investigating the issue should be to conduct a Holter monitor test after conducting initial blood tests and an ECG. Palpitations are often indicative of an arrhythmia, such as atrial fibrillation, and it is important to conduct further investigations to rule out this possibility.

      Holter monitoring is the recommended first-line investigation to capture any episodes of arrhythmia. Since the patient experiences these episodes daily, a 24-hour monitoring period is appropriate. However, a troponin test is not necessary as there is no chest pain, and an echocardiogram is not warranted as there are no indications of heart failure.

      If the Holter monitoring results are normal and the patient continues to experience symptoms, an external loop recorder may be considered.

      Investigating Palpitations: Identifying Possible Causes and Capturing Episodic Arrhythmias

      Palpitations are a common symptom that can be caused by various factors such as arrhythmias, stress, and increased awareness of normal heartbeats. To investigate the underlying cause of palpitations, first-line investigations include a 12-lead ECG, thyroid function tests, urea and electrolytes, and a full blood count. However, these investigations may not capture episodic arrhythmias, which are often missed during a short ECG recording.

      To capture episodic arrhythmias, the most common investigation is Holter monitoring. This portable battery-operated device continuously records ECG from 2-3 leads for 24 hours or longer if symptoms are less than daily. Patients are asked to keep a diary to record any symptomatic palpitations, which can later be compared to the rhythm strip at the time of the symptoms. At the end of the monitoring, a report is generated summarizing heart rate, arrhythmias, and changes in ECG waveform.

      If no abnormality is found on the Holter monitor and symptoms persist, other options include an external loop recorder or an implantable loop recorder. These investigations can help identify the underlying cause of palpitations and guide appropriate management.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 24 - A 50-year-old woman has been diagnosed with an unprovoked proximal deep vein thrombosis....

    Incorrect

    • 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:

      Correct 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
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  • Question 25 - A 39-year-old man presents with gingival hypertrophy.

    Which of his cardiac medications is likely...

    Incorrect

    • A 39-year-old man presents with gingival hypertrophy.

      Which of his cardiac medications is likely to be responsible?

      Your Answer:

      Correct Answer: Atenolol

      Explanation:

      Gingival Hypertrophy and Medications

      Gingival hypertrophy, or an overgrowth of gum tissue, can be caused by certain medications. Calcium channel blockers, such as amlodipine, as well as drugs like phenytoin and cyclosporin, have been associated with this side effect. It is important for patients taking these medications to maintain good oral hygiene and regularly visit their dentist to monitor any changes in their gum tissue. If gingival hypertrophy does occur, treatment options may include scaling and root planing, gingivectomy, or medication adjustments. Awareness of this potential side effect can help patients and healthcare providers make informed decisions about medication management.

    • This question is part of the following fields:

      • 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.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 27 - A 47-year-old man has recently been prescribed apixaban by his haematologist after experiencing...

    Incorrect

    • A 47-year-old man has recently been prescribed apixaban by his haematologist after experiencing a pulmonary embolism. He is currently taking other medications for his co-existing conditions. Can you identify which of his medications may potentially interact with apixaban?

      Your Answer:

      Correct Answer: Carbamazepine

      Explanation:

      If anticoagulation is being used for deep vein thrombosis or pulmonary embolism, the British National Formulary recommends avoiding the simultaneous use of apixaban and carbamazepine. This is because carbamazepine may lower the plasma concentration of apixaban. No interactions have been identified between apixaban and the other options listed.

      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
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      Seconds
  • Question 28 - 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.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 29 - A 65-year-old patient presents at the local walk-in centre with central crushing chest...

    Incorrect

    • A 65-year-old patient presents at the local walk-in centre with central crushing chest pain. The nurse immediately calls 999 and performs an ECG which reveals ST elevation in leads II, III and aVF. The patient's blood pressure is 130/70 mmHg, pulse rate is 90 beats per minute, and oxygen saturation is 96%. What is the most suitable course of action to take while waiting for the ambulance to arrive?

      Your Answer:

      Correct Answer: Aspirin 300 mg + sublingual glyceryl trinitrate

      Explanation:

      Assessment of Patients with Suspected Cardiac Chest Pain

      Patients presenting with acute chest pain should receive immediate management for suspected acute coronary syndrome (ACS), including glyceryl trinitrate and aspirin 300 mg. Oxygen should only be given if sats are less than 94%. A normal ECG doesn’t exclude ACS, so referral should be made based on the timing of chest pain and ECG results. Patients with current chest pain or chest pain in the last 12 hours with an abnormal ECG should be emergency admitted. Those with chest pain 12-72 hours ago should be referred to the hospital the same day for assessment. Chest pain more than 72 hours ago should undergo a full assessment with ECG and troponin measurement before deciding upon further action.

      For patients presenting with stable chest pain, NICE defines anginal pain as constricting discomfort in the front of the chest, neck, shoulders, jaw, or arms, precipitated by physical exertion, and relieved by rest or GTN in about 5 minutes. Patients with all three features have typical angina, those with two have atypical angina, and those with one or none have non-anginal chest pain. If stable angina cannot be excluded by clinical assessment alone, NICE recommends CT coronary angiography as the first line of investigation, followed by non-invasive functional imaging and invasive coronary angiography as second and third lines, respectively. Non-invasive functional imaging options include myocardial perfusion scintigraphy with single photon emission computed tomography, stress echocardiography, first-pass contrast-enhanced magnetic resonance perfusion, and MR imaging for stress-induced wall motion abnormalities.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 30 - A 17-year-old girl collapses and dies during a track meet at school. She...

    Incorrect

    • A 17-year-old girl collapses and dies during a track meet at school. She had no significant medical history. Upon post-mortem examination, it is discovered that she had asymmetric hypertrophy of the interventricular septum. What is the probability that her sister also has this condition?

      Your Answer:

      Correct Answer: 50%

      Explanation:

      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.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 31 - A 50-year-old man comes to see you to ask about travel to India...

    Incorrect

    • A 50-year-old man comes to see you to ask about travel to India to visit his relatives. He has been discharged recently from the local district general hospital after suffering an inferior myocardial infarction. He had an exercise test prior to discharge and has made a good recovery. He looks well wants to return to his family home to Mumbai to recuperate.

      According to the UK Civil Aviation Authority, what is the minimum time after an uncomplicated MI that he would be OK to fly home?

      Your Answer:

      Correct Answer: 7 days

      Explanation:

      Travel Restrictions After Myocardial Infarction

      After experiencing a myocardial infarction (MI), also known as a heart attack, patients may wonder when it is safe to travel by air. The minimum time for flying after an uncomplicated MI is generally accepted to be seven days, although some authorities suggest waiting up to three weeks. It is important to note that this question specifically asks for the minimum time after an uncomplicated MI that would be safe for air travel.

      Consensus national guidance in the UK, including advice from the Civil Aviation Authority and British Airways, supports the seven-day minimum for uncomplicated MI. Patients who have had a complicated MI should wait four to six weeks before flying. Patients with severe angina may require oxygen during the flight and should pre-book a supply with the airline. Patients who have undergone coronary artery bypass graft (CABG) or suffered a stroke should not travel for ten days. Decompensated heart failure or uncontrolled hypertension are contraindications to flying.

      In summary, patients who have experienced an uncomplicated MI may fly after seven days without requiring an exercise test. It is important to follow national guidance and consult with a healthcare provider before making any travel plans after a heart attack.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 32 - A 45-year-old woman presents to her General Practitioner with a 3-month history of...

    Incorrect

    • A 45-year-old woman presents to her General Practitioner with a 3-month history of progressive exercise intolerance. Four weeks ago, she experienced an episode suggestive of paroxysmal nocturnal dyspnoea. Examination reveals a jugular venous pressure (JVP) raised up to her earlobes, soft, tender hepatomegaly and bilateral pitting oedema up to her ankles. Chest examination reveals bibasal crepitations and an audible S3 on auscultation of the heart. The chest X-ray shows cardiomegaly with interstitial infiltrates. Echocardiography shows global left ventricular hypokinesia with an ejection fraction of 20–25%. She has no other significant medical history.
      Which of the following is the most likely underlying causal factor in this patient?

      Your Answer:

      Correct Answer: Autosomal dominant genetic trait

      Explanation:

      Understanding Dilated Cardiomyopathy and its Causes

      Dilated cardiomyopathy is a progressive disease of the heart muscle that causes stretching and dilatation of the left ventricle, resulting in contractile dysfunction. This condition can also affect the right ventricle, leading to congestive cardiac failure. While it is a heterogeneous condition with multiple causal factors, about 35% of cases are inherited as an autosomal dominant trait. Other causes include autoimmune reactions, hypertension, connective tissue disorders, metabolic causes, malignancy, neuromuscular causes, and chronic alcohol abuse. Rarely, amyloidosis and Marfan syndrome can also cause dilated cardiomyopathy. Ischaemic heart disease is not the most common cause in an otherwise healthy 30-year-old patient. While HIV infection can cause dilated cardiomyopathy, it is not a common cause, and it would be rare for this complication to be the first presentation of HIV. Understanding the various causes of dilated cardiomyopathy can help in its diagnosis and management.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 33 - An 80-year-old woman is brought to the clinic by her family members. She...

    Incorrect

    • An 80-year-old woman is brought to the clinic by her family members. She has been experiencing increasing shortness of breath and low energy levels for the past 6 weeks. Upon conducting an ECG, it is revealed that she has atrial fibrillation with a heart rate of 114 / min. Her blood pressure is 128/80 mmHg and a chest x-ray shows no abnormalities. What medication should be prescribed to manage her heart rate?

      Your Answer:

      Correct Answer: Bisoprolol

      Explanation:

      When it comes to rate control in atrial fibrillation, beta blockers are now the preferred option over digoxin. This is an important point to remember, especially for exams. The patient’s shortness of breath may be related to her heart rate and not necessarily a sign of heart failure, as her chest x-ray was normal. For more information, refer to the NICE guidelines.

      Atrial fibrillation (AF) is a heart condition that requires prompt management. The management of AF depends on the patient’s haemodynamic stability and the duration of the AF. For haemodynamically unstable patients, electrical cardioversion is recommended. For haemodynamically stable patients, rate control is the first-line treatment strategy, except in certain cases. Medications such as beta-blockers, calcium channel blockers, and digoxin are commonly used to control the heart rate. Rhythm control is another treatment option that involves the use of medications such as beta-blockers, dronedarone, and amiodarone. Catheter ablation is recommended for patients who have not responded to or wish to avoid antiarrhythmic medication. The procedure involves the use of radiofrequency or cryotherapy to ablate the faulty electrical pathways that cause AF. Anticoagulation is necessary before and during the procedure to reduce the risk of stroke. The success rate of catheter ablation varies, with around 50% of patients experiencing an early recurrence of AF within three months. However, after three years, around 55% of patients who have undergone a single procedure remain in sinus rhythm.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 34 - A 64-year-old man who underwent mechanical mitral valve replacement four years ago is...

    Incorrect

    • A 64-year-old man who underwent mechanical mitral valve replacement four years ago is being evaluated. What is the probable long-term antithrombotic treatment he is receiving?

      Your Answer:

      Correct Answer: Warfarin

      Explanation:

      Antithrombotic therapy for prosthetic heart valves differs depending on the type of valve. Bioprosthetic valves typically only require aspirin, while mechanical valves require both warfarin and aspirin. However, according to the 2017 European Society of Cardiology guidelines, aspirin is only given in addition if there is another indication, such as ischaemic heart disease. Direct acting oral anticoagulants are not used for patients with a mechanical heart valve.

      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.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 35 - A 35-year-old gentleman has come to discuss the result of a routine annual...

    Incorrect

    • A 35-year-old gentleman has come to discuss the result of a routine annual blood test at work. He is otherwise well with no symptoms reported.

      He was found to have a serum phosphate of 0.7.
      Other tests done include FBC, U+Es, LFTs, Calcium and PTH which were all normal.
      Serum phosphate normal range (0-8-1.4 mmol/L)

      What is the most appropriate next step in management?

      Your Answer:

      Correct Answer: Ultrasound neck

      Explanation:

      Management of Mild Hypophosphataemia

      In cases of mild hypophosphataemia, monitoring is often sufficient. It may be helpful to check vitamin D levels as it can affect phosphate uptake and renal excretion, along with parathyroid hormone (PTH). If there is a concurrent low magnesium level, it may indicate dietary deficiencies.

      An ultrasound of the neck is not necessary unless there are signs of enlarged parathyroid glands. Oral phosphate is typically reserved for preventing refeeding syndrome in cases of anorexia, starvation, or alcoholism. Mild hypophosphataemia usually resolves on its own.

      Parenteral phosphate may be considered in acute situations but requires inpatient monitoring of calcium, phosphate, and other electrolytes. Referral should only be considered if the patient is symptomatic, has short stature or skeletal deformities consistent with rickets, or if the hypophosphataemia is chronic or severe.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 36 - A 65-year-old woman presents at the GP practice with increasing shortness of breath...

    Incorrect

    • A 65-year-old woman presents at the GP practice with increasing shortness of breath (SOB). She experiences SOB on exertion and when lying down at night. Her symptoms have been gradually worsening over the past few weeks. She is an ex-smoker and is not taking any regular medication. During examination, she appears comfortable at rest, heart sounds are normal, and there are bibasal crackles. She has pitting edema to the mid-calf bilaterally. Observations reveal a pulse of 89 bpm, oxygen saturations of 96%, respiratory rate of 12/min, and blood pressure of 192/128 mmHg.

      What would be the most appropriate course of action?

      Your Answer:

      Correct Answer: Refer for acute medical admission

      Explanation:

      If the patient has a new BP reading of 180/120 mmHg or higher and is experiencing new-onset confusion, chest pain, signs of heart failure, or acute kidney injury, they should be admitted for specialist assessment. This is the correct course of action for this patient, as she has a BP reading above 180/120 mmHg and is showing signs of heart failure. Other indications for admission with a BP reading above 180/120 mmHg include new-onset confusion, chest pain, or acute kidney injury.

      Arranging an outpatient echocardiogram and chest x-ray is not the appropriate action for this patient. While these investigations may be necessary, the patient should be admitted for specialized assessment to avoid any unnecessary delays.

      Commencing a long-acting bronchodilator (LABA) is not the correct course of action for this patient. While COPD may be a differential diagnosis, the signs of heart failure and new hypertension require a referral for acute medical assessment.

      Commencing furosemide is not the appropriate action for this patient. While it may improve her symptoms, it will not address the underlying cause of her heart failure. Therefore, she requires further investigation and treatment, most appropriately with an acute medical admission.

      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 37 - A 58-year-old man comes to his GP complaining of headaches and blurred vision...

    Incorrect

    • A 58-year-old man comes to his GP complaining of headaches and blurred vision that have been present for two days. He has been taking amlodipine 5 mg, which was prescribed at the same clinic two weeks ago. During the examination, his blood pressure is measured at 190/115 mmHg. Although his cardiovascular examination is unremarkable, retinal hemorrhages are observed during fundoscopy, but no papilledema is present. What is the best course of action for this patient?

      Your Answer:

      Correct Answer: Refer for urgent specialist care on the same day

      Explanation:

      NICE Guidelines for Referral to Specialist Care for Hypertension

      According to NICE guidelines, patients with accelerated hypertension or suspected phaeochromocytoma should be referred to specialist care on the same day. Accelerated hypertension is defined as having a blood pressure usually higher than 180/120 mmHg with signs of papilloedema and/or retinal haemorrhage. Suspected phaeochromocytoma is characterized by labile or postural hypotension, headache, palpitations, pallor, and diaphoresis.

      It is important to note that if a patient presents with a blood pressure higher than 180/120 mmHg, it is crucial to examine their fundi and check for the presence or absence of papilloedema or retinal haemorrhages. Additionally, healthcare professionals should consider the need for specialist investigations in patients with signs and symptoms suggesting a secondary cause of hypertension. By following these guidelines, healthcare professionals can ensure that patients receive appropriate and timely care for their hypertension.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 38 - Which treatment for hypercholesterolaemia in primary prevention trials has been shown to reduce...

    Incorrect

    • Which treatment for hypercholesterolaemia in primary prevention trials has been shown to reduce all cause mortality?

      Your Answer:

      Correct Answer: Statins

      Explanation:

      Lipid Management in Primary Care

      Lipid management is a common scenario in primary care, and NICE has produced guidance on Lipid modification (CG181) in the primary and secondary prevention of cardiovascular disease. The use of statins in primary prevention is supported by clinical trial data, with WOSCOPS (The West of Scotland Coronary Prevention Study) being a landmark trial. This study looked at statin versus placebo in men aged 45-65 with no coronary disease and a cholesterol >4 mmol/L, showing a reduction in all-cause mortality by 22% in the statin arm for a 20% total cholesterol reduction.

      Other study data also supports the use of statins as primary prevention of coronary artery disease. The NICE Clinical Knowledge Summary on lipid modification – CVD prevention recommends Atorvastatin at 20 mg for primary prevention and 80 mg for secondary prevention. Risk is assessed using the QRISK2 calculator. Overall, lipid management is an important aspect of primary care, and healthcare professionals should be familiar with the latest guidance and clinical trial data to provide optimal care for their patients.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 39 - 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
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  • Question 40 - You are evaluating a 75-year-old man with longstanding varicose veins. He presents to...

    Incorrect

    • You are evaluating a 75-year-old man with longstanding varicose veins. He presents to you with a small painful ulcer near one of them. The pain improves when he elevates his leg.

      During the examination, you observe normal distal pulses and warm feet. The ulcer is well-defined and shallow, with a small amount of slough and granulation tissue at the base.

      The patient has never smoked, has no significant past medical history, and recent blood tests, including an HbA1c, were normal.

      You suspect a venous ulcer and plan to perform an ankle-brachial pressure index (ABPI) to initiate compression bandaging.

      As per current NICE guidelines, what is the most appropriate next step in management?

      Your Answer:

      Correct Answer: Refer to vascular team

      Explanation:

      Referral to secondary care for treatment is recommended for patients with varicose veins and an active or healed venous leg ulcer. In this case, the woman should be referred to the vascular team. Venous leg ulcers can be painful and are associated with venous stasis. Class 2 compression stockings are used for the treatment of uncomplicated varicose veins. Small amounts of slough and granulation tissue are common with venous ulcers and do not necessarily indicate an infection requiring antibiotics. Exercise is encouraged to help venous return in these patients. Duplex sonography is usually performed in secondary care, but the specialist team will request this, not primary care.

      Understanding Varicose Veins

      Varicose veins are enlarged and twisted veins that occur when the valves in the veins become weak or damaged, causing blood to flow backward and pool in the veins. They are most commonly found in the legs and can be caused by various factors such as age, gender, pregnancy, obesity, and genetics. While many people seek treatment for cosmetic reasons, others may experience symptoms such as aching, throbbing, and itching. In severe cases, varicose veins can lead to skin changes, bleeding, superficial thrombophlebitis, and venous ulceration.

      To diagnose varicose veins, a venous duplex ultrasound is typically performed to detect retrograde venous flow. Treatment options vary depending on the severity of the condition. Conservative treatments such as leg elevation, weight loss, regular exercise, and compression stockings may be recommended for mild cases. However, patients with significant or troublesome symptoms, skin changes, or a history of bleeding or ulcers may require referral to a specialist for further evaluation and treatment. Possible treatments include endothermal ablation, foam sclerotherapy, or surgery.

      In summary, varicose veins are a common condition that can cause discomfort and cosmetic concerns. While many cases do not require intervention, it is important to seek medical attention if symptoms or complications arise. With proper diagnosis and treatment, patients can manage their condition and improve their quality of life.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 41 - A 42-year-old white male is diagnosed with hypertension.

    He is usually fit and well...

    Incorrect

    • A 42-year-old white male is diagnosed with hypertension.

      He is usually fit and well with no significant past medical history. His ECG is normal, he has no microalbuminuria, and clinical examination is otherwise unremarkable.

      Assuming there are no contraindications, place the following in the correct order in which they should be initiated to manage his high blood pressure:

      A ACE-inhibitor
      B Calcium channel blocker
      C Thiazide-like diuretic
      D Alpha blocker

      Your Answer:

      Correct Answer: C A B D

      Explanation:

      NICE Guidelines for Hypertension Treatment

      There are established guidelines published by NICE for managing high blood pressure. The guidelines outline a stepwise approach to pharmacological treatment. For patients under 55 years old and not of black African or Caribbean ethnic origin, the first-line treatment is an ACE inhibitor or a low-cost angiotensin receptor II antagonist. If additional treatment is needed, a calcium-channel blocker should be added, followed by a thiazide-like diuretic. If a fourth agent is required, options include a further diuretic, an alpha-blocker, or a beta-blocker. Spironolactone can be used if the patient’s potassium level is 4.5 mmol/L or less. If not, an alpha- or beta-blocker can be considered.

      For patients of black African or Caribbean ethnic origin of any age (and all those over 55), the first-line antihypertensive treatment is a calcium-channel blocker. If the calcium-channel blocker is not tolerated or contraindicated, then a thiazide-like diuretic would be first-line. If additional treatment is required, an ACE-inhibitor (or a low-cost angiotensin receptor II antagonist) should be added, followed by a thiazide-like diuretic. If necessary, a further diuretic (spironolactone), an alpha-blocker, or a beta-blocker can be considered.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 42 - 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.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 43 - A 55-year-old female patient presents to your morning clinic with complaints of pain...

    Incorrect

    • A 55-year-old female patient presents to your morning clinic with complaints of pain and cramps in her right calf. She has also observed some brown discoloration around her right ankle. Her symptoms have been progressing for the past few weeks. She had been treated for a right-sided posterior tibial deep vein thrombosis (DVT) six months ago. Upon examination, she appears to be in good health.

      What would be the best course of action for managing this patient?

      Your Answer:

      Correct Answer: Compression stockings

      Explanation:

      Compression stockings should only be offered to patients with deep vein thrombosis who are experiencing post-thrombotic syndrome (PTS), which typically occurs 6 months to 2 years after the initial DVT and is characterized by chronic pain, swelling, hyperpigmentation, and venous ulcers. Apixaban is not appropriate for treating PTS, as it is used to treat acute DVT. Codeine may help with pain but doesn’t address the underlying cause. Hirudoid cream is not effective for treating PTS, as it is used for superficial thrombophlebitis. If conservative management is not effective, patients may be referred to vascular surgery for surgical treatment. Compression stockings are the first-line treatment for PTS, as they improve blood flow and reduce symptoms in the affected calf.

      Post-Thrombotic Syndrome: A Complication of Deep Vein Thrombosis

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

      While compression stockings were previously recommended to reduce the risk of post-thrombotic syndrome in patients with DVT, Clinical Knowledge Summaries now advise against their use for this purpose. However, compression stockings are still recommended as a treatment for post-thrombotic syndrome. Other recommended treatments include keeping the affected leg elevated.

      In summary, post-thrombotic syndrome is a potential complication of DVT that can cause a range of uncomfortable symptoms. While compression stockings are no longer recommended for prevention, they remain an important treatment option for those who develop the syndrome.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 44 - An 80 year old male underwent an ECG due to palpitations and was...

    Incorrect

    • An 80 year old male underwent an ECG due to palpitations and was found to have AF with a heart rate of 76 bpm. Upon further evaluation, you determine that he has permanent AF and a history of hypertension. If there are no contraindications, what would be the most suitable initial step to take at this point?

      Your Answer:

      Correct Answer: Direct oral anticoagulant

      Explanation:

      According to the patient’s CHADSVASC2 score, which is 4, they have a high risk of stroke due to factors such as congestive cardiac failure, hypertension, age over 75, and being female. As per NICE guidelines, all patients with a CHADSVASC score of 2 or more should be offered anticoagulation, while taking into account their bleeding risk using the ORBIT score. Direct oral anticoagulants are now preferred over warfarin as the first-line treatment. For men with a score of 1, anticoagulation should be considered. Beta-blockers or a rate-limiting calcium channel blocker should be offered first-line for rate control, while digoxin should only be used for sedentary patients.

      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.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 45 - A 60-year-old man with no medication history comes in with three high blood...

    Incorrect

    • A 60-year-old man with no medication history comes in with three high blood pressure readings of 155/95 mmHg, 160/100 mmHg, and 164/85 mmHg.

      What is the probable diagnosis?

      Your Answer:

      Correct Answer: Essential hypertension

      Explanation:

      Understanding Hypertension

      Ninety five percent of patients diagnosed with hypertension have essential or primary hypertension, while the remaining five percent have secondary hypertension. Essential hypertension is caused by a combination of genetic and environmental factors, resulting in high blood pressure. On the other hand, secondary hypertension is caused by a specific abnormality in one of the organs or systems of the body.

      It is important to understand the type of hypertension a patient has in order to determine the appropriate treatment plan. While essential hypertension may be managed through lifestyle changes and medication, secondary hypertension requires addressing the underlying cause. Regular blood pressure monitoring and consultation with a healthcare professional can help manage hypertension and reduce the risk of complications.

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      • Cardiovascular Health
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  • Question 46 - Sophie is a 65-year-old woman who has recently been diagnosed with atrial fibrillation...

    Incorrect

    • Sophie is a 65-year-old woman who has recently been diagnosed with atrial fibrillation after experiencing some palpitations. She has no other medical history and only takes atorvastatin for high cholesterol. She has no symptoms currently and her observations are stable with a heart rate of 75 beats per minute. Her CHA2DS2-VASc score is 0.

      What would be the appropriate next step in managing Sophie's condition?

      Your Answer:

      Correct Answer: Arrange for an echocardiogram

      Explanation:

      When a patient with atrial fibrillation has a CHA2DS2-VASc score that suggests they do not need anticoagulation, it is recommended to perform a transthoracic echo to rule out valvular heart disease. The CHA2DS2-VASc score is used to assess the risk of stroke in AF patients, and anticoagulant treatment is generally indicated for those with a score of two or more. Rivaroxaban is an anticoagulant that can be used in AF, but it is not necessary in this scenario. Aspirin should not be used to prevent stroke in AF patients. If a patient requires rate control for fast AF, beta-blockers are the first line of treatment. Digoxin is only used for patients with a more sedentary lifestyle and doesn’t protect against stroke. It is important to perform a transthoracic echo in AF patients, especially if it may change their management or refine their risk of stroke and need for anticoagulation.

      Atrial fibrillation (AF) is a condition that requires careful management, including the use of anticoagulation therapy. The latest guidelines from NICE recommend assessing the need for anticoagulation in all patients with a history of AF, regardless of whether they are currently experiencing symptoms. The CHA2DS2-VASc scoring system is used to determine the most appropriate anticoagulation strategy, with a score of 2 or more indicating the need for anticoagulation. However, it is important to ensure a transthoracic echocardiogram has been done to exclude valvular heart disease, which is an absolute indication for anticoagulation.

      When considering anticoagulation therapy, doctors must also assess the patient’s bleeding risk. NICE recommends using the ORBIT scoring system to formalize this risk assessment, taking into account factors such as haemoglobin levels, age, bleeding history, renal impairment, and treatment with antiplatelet agents. While there are no formal rules on how to act on the ORBIT score, individual patient factors should be considered. The risk of bleeding increases with a higher ORBIT score, with a score of 4-7 indicating a high risk of bleeding.

      For many years, warfarin was the anticoagulant of choice for AF. However, the development of direct oral anticoagulants (DOACs) has changed this. DOACs have the advantage of not requiring regular blood tests to check the INR and are now recommended as the first-line anticoagulant for patients with AF. The recommended DOACs for reducing stroke risk in AF are apixaban, dabigatran, edoxaban, and rivaroxaban. Warfarin is now used second-line, in patients where a DOAC is contraindicated or not tolerated. Aspirin is not recommended for reducing stroke risk in patients with AF.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 47 - A 75 year old man has come for a surgical consultation regarding an...

    Incorrect

    • A 75 year old man has come for a surgical consultation regarding an ambulatory blood pressure monitoring reading of 142/84 mmHg. He has no history of coronary heart disease, renal disease or diabetes, and is only taking lansoprazole regularly. His 10-year cardiovascular risk score was recently assessed to be 8%. Which of the following should be included in his management plan for follow up?

      Your Answer:

      Correct Answer: Lifestyle advice

      Explanation:

      When a patient is diagnosed with stage 2 hypertension, regardless of their age, it is recommended to start antihypertensive medication and reinforce lifestyle advice.

      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 48 - The nurse practitioner approaches you with a query after the clinic. A 50-year-old...

    Incorrect

    • The nurse practitioner approaches you with a query after the clinic. A 50-year-old patient had visited her for a regular diabetes check-up and disclosed a history of a minor stroke during a trip abroad a few years ago. The nurse observed that this information was not included in the problem list, so she updated the record with a coded diagnosis. As a result, a computer alert was triggered since the patient was not taking any antiplatelet therapy. The nurse seeks your advice on the preferred antiplatelet medication for this patient.

      Your Answer:

      Correct Answer: Clopidogrel

      Explanation:

      Clopidogrel is the top choice for antiplatelet therapy in the secondary prevention of stroke. As a second option, aspirin can be combined with modified-release dipyridamole. However, there is some discrepancy among guidelines regarding the preferred antiplatelet for transient ischaemic attack. While NICE recommends aspirin and dipyridamole due to clopidogrel lack of licensing for this indication, the Royal College of Physicians advocates for clopidogrel. It is worth noting that clopidogrel is associated with frequent gastrointestinal side effects.

      The Royal College of Physicians (RCP) and NICE have published guidelines on the diagnosis and management of patients following a stroke. The guidelines provide recommendations for the management of acute stroke, including maintaining normal levels of blood glucose, hydration, oxygen saturation, and temperature. Blood pressure should not be lowered in the acute phase unless there are complications. Aspirin should be given as soon as possible if a haemorrhagic stroke has been excluded. Anticoagulants should not be started until brain imaging has excluded haemorrhage, and usually not until 14 days have passed from the onset of an ischaemic stroke. If the cholesterol is > 3.5 mmol/l, patients should be commenced on a statin.

      Thrombolysis with alteplase should only be given if it is administered within 4.5 hours of onset of stroke symptoms and haemorrhage has been definitively excluded. There are absolute and relative contraindications to thrombolysis, including previous intracranial haemorrhage, intracranial neoplasm, and active bleeding. Mechanical thrombectomy is a new treatment option for patients with an acute ischaemic stroke. NICE recommends considering thrombectomy together with intravenous thrombolysis for people last known to be well up to 24 hours previously.

      Secondary prevention recommendations from NICE include the use of clopidogrel and dipyridamole. Clopidogrel is recommended ahead of combination use of aspirin plus modified-release dipyridamole in people who have had an ischaemic stroke. Aspirin plus MR dipyridamole is recommended after an ischaemic stroke only if clopidogrel is contraindicated or not tolerated. MR dipyridamole alone is recommended after an ischaemic stroke only if aspirin or clopidogrel are contraindicated or not tolerated. Carotid artery endarterectomy should only be considered if carotid stenosis is greater than 70% according to ECST criteria or greater than 50% according to NASCET criteria.

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      • Cardiovascular Health
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  • Question 49 - A 48-year-old Caucasian female presents with tiredness to her general practitioner. She has...

    Incorrect

    • A 48-year-old Caucasian female presents with tiredness to her general practitioner. She has gained a little weight of late and during the last year has become increasingly tired. She has a history of asthma for which she takes inhaled salbutamol on an as required basis (usually no more than once a week) and diet-controlled type 2 diabetes.

      Examination reveals a blood pressure of 172/98 mmHg, a body mass index of 29.7 kg/m2, and a pulse of 88 beats per minute. There are no other abnormalities of note. Her blood pressure recordings over the next month are 180/96, 176/90 and 178/100 mmHg.

      Which of the following drugs would you recommend for the treatment of this patient's blood pressure?

      Your Answer:

      Correct Answer: Atenolol

      Explanation:

      Hypertension Treatment in Type 2 Diabetes Patients

      This patient with type 2 diabetes has sustained hypertension and requires treatment. The first-line treatment for hypertension in diabetes is ACE inhibitors. These medications have no adverse effects on glucose tolerance or lipid profiles and can delay the progression of microalbuminuria to nephropathy. Additionally, ACE inhibitors reduce morbidity and mortality in patients with vascular disease and diabetes.

      However, bendroflumethiazide may provoke an attack of gout in patients with a history of gout. Beta-blockers should be avoided for the routine treatment of uncomplicated hypertension in patients with diabetes. They can also precipitate bronchospasm and should be avoided in patients with asthma. In situations where there is no suitable alternative, a cardioselective beta blocker should be selected and initiated at a low dose by a specialist. The patient should be monitored closely for adverse effects.

      Alpha-blockers, such as doxazosin, are reserved for the treatment of resistant hypertension in conjunction with other antihypertensives. It is important to consider the patient’s medical history and individual needs when selecting a treatment plan for hypertension in type 2 diabetes patients.

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      • Cardiovascular Health
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  • Question 50 - A 75 year old woman comes to the Emergency Department with gradual onset...

    Incorrect

    • A 75 year old woman comes to the Emergency Department with gradual onset of dyspnea. During the examination, the patient exhibits an S3 gallop rhythm, bibasal crackles, and pitting edema up to both knees. An electrocardiogram reveals indications of left ventricular hypertrophy, and a chest X-ray shows small bilateral pleural effusions, cardiomegaly, and upper lobe diversion.

      Considering the probable diagnosis, which of the following medications has been demonstrated to enhance long-term survival?

      Your Answer:

      Correct Answer: Ramipril

      Explanation:

      The patient exhibits symptoms of congestive heart failure, which can be managed with loop diuretics and nitrates in acute or decompensated cases. However, these medications do not improve long-term survival. To reduce mortality in patients with left ventricular failure, ACE-inhibitors, beta-blockers, angiotensin receptor blockers, aldosterone antagonists, and hydralazine with nitrates have all been proven effective. Digoxin can reduce hospital admissions but not mortality, and is typically used in patients with worsening heart failure despite initial treatments or those with co-existing atrial fibrillation.

      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 51 - A 68-year-old patient has a cholesterol level of 5.1 mmol/L and a QRISK...

    Incorrect

    • A 68-year-old patient has a cholesterol level of 5.1 mmol/L and a QRISK score of 11%. They lead an active lifestyle and have no significant medical history. What is the best course of action for managing these findings?

      Your Answer:

      Correct Answer: Commence atorvastatin

      Explanation:

      Based on the QRISK score, it appears that dietary changes alone may not be enough to lower the risk of cardiovascular disease to a satisfactory level.

      Statins are drugs that inhibit the action of HMG-CoA reductase, which is the enzyme responsible for cholesterol synthesis in the liver. However, they can cause adverse effects such as myopathy, liver impairment, and an increased risk of intracerebral hemorrhage in patients with a history of stroke. Statins should not be taken during pregnancy or in combination with macrolides. NICE recommends statins for patients with established cardiovascular disease, a 10-year cardiovascular risk of 10% or higher, type 2 diabetes mellitus, or type 1 diabetes mellitus with certain criteria. It is recommended to take statins at night, especially simvastatin, which has a shorter half-life than other statins. NICE recommends atorvastatin 20 mg for primary prevention and atorvastatin 80 mg for secondary prevention.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 52 - A 49-year-old accountant presents with severe central chest pain. An ECG shows ST...

    Incorrect

    • A 49-year-old accountant presents with severe central chest pain. An ECG shows ST elevation in leads II, III and aVF. The patient undergoes percutaneous coronary intervention and a right coronary artery occlusion is successfully stented. Post-procedure, there are no complications and echocardiography shows an ejection fraction of 50%. The patient inquires about the impact on his driving as he relies on his car for commuting to work. What guidance should you provide regarding his ability to drive?

      Your Answer:

      Correct Answer: Stop driving for at least 1 week, no need to inform the DVLA

      Explanation:

      Driving can resume after hospital discharge if the patient has successfully undergone coronary angioplasty and there are no other disqualifying conditions. However, if the patient is a bus, taxi, or lorry driver, they must inform the DVLA and refrain from driving for a minimum of 6 weeks.

      DVLA Guidelines for Cardiovascular Disorders and Driving

      The DVLA has specific guidelines for individuals with cardiovascular disorders who wish to drive a car or motorcycle. For those with hypertension, driving is permitted unless the treatment causes unacceptable side effects, and there is no need to notify the DVLA. However, if the individual has Group 2 Entitlement, they will be disqualified from driving if their resting blood pressure consistently measures 180 mmHg systolic or more and/or 100 mm Hg diastolic or more.

      Individuals who have undergone elective angioplasty must refrain from driving for one week, while those who have undergone CABG or acute coronary syndrome must wait four weeks before driving. If an individual experiences angina symptoms at rest or while driving, they must cease driving altogether. Pacemaker insertion requires a one-week break from driving, while implantable cardioverter-defibrillator (ICD) implantation results in a six-month driving ban if implanted for sustained ventricular arrhythmia. If implanted prophylactically, the individual must cease driving for one month, and Group 2 drivers are permanently barred from driving with an ICD.

      Successful catheter ablation for an arrhythmia requires a two-day break from driving, while an aortic aneurysm of 6 cm or more must be reported to the DVLA. Licensing will be permitted subject to annual review, but an aortic diameter of 6.5 cm or more disqualifies patients from driving. Finally, individuals who have undergone a heart transplant must refrain from driving for six weeks, but there is no need to notify the DVLA.

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      • Cardiovascular Health
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  • Question 53 - A 75-year-old male comes to the Emergency Department complaining of increased swelling in...

    Incorrect

    • A 75-year-old male comes to the Emergency Department complaining of increased swelling in his right leg. He has a medical history of right-sided heart failure. During the examination, his right calf is found to be 3 cm larger than his left and he has bilateral pitting oedema up to the knee. A positive D-dimer result prompts the initiation of apixaban. However, an ultrasound scan of his leg comes back negative.

      What would be the most suitable course of action?

      Your Answer:

      Correct Answer: Stop anticoagulation and repeat scan in 1 week

      Explanation:

      If a D-dimer test is positive but an ultrasound scan for possible deep vein thrombosis (DVT) is negative, the recommended course of action is to stop anticoagulation and repeat the scan in one week. It is not appropriate to simply discharge the patient with worsening advice, as a follow-up scan is necessary to ensure that a clot has not been missed. Continuing anticoagulation would only be appropriate if the scan had shown a positive result. It is not recommended to continue anticoagulation for three or six months, as these are management strategies for a confirmed DVT that has been detected by a positive ultrasound scan.

      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 54 - A 44-year-old woman has been released from the nearby stroke unit following a...

    Incorrect

    • A 44-year-old woman has been released from the nearby stroke unit following a lacunar ischaemic stroke. She has a history of hypertension and is a smoker who is currently taking lisinopril. However, her discharge medications do not include a statin. What would be the most suitable prescription for initiating statin therapy?

      Your Answer:

      Correct Answer: Atorvastatin 80 mg

      Explanation:

      For primary prevention of cardiovascular disease, atorvastatin 20 mg is recommended, while for secondary prevention, the dose is increased to 80 mg. The patient was previously not on statin therapy for primary prevention despite being hypertensive. However, after experiencing a confirmed vascular event, the patient now requires the higher dose of atorvastatin for secondary prevention as per current guidelines. Simvastatin is not the preferred choice for secondary prevention and neither the 40 mg nor the 20 mg dose would be appropriate. Atorvastatin 10 mg is not recommended for secondary prevention, and the 20 mg dose is only licensed for primary prevention. High-intensity statin treatment is recommended for both primary and secondary prevention.

      Statins are drugs that inhibit the action of HMG-CoA reductase, which is the enzyme responsible for cholesterol synthesis in the liver. However, they can cause adverse effects such as myopathy, liver impairment, and an increased risk of intracerebral hemorrhage in patients with a history of stroke. Statins should not be taken during pregnancy or in combination with macrolides. NICE recommends statins for patients with established cardiovascular disease, a 10-year cardiovascular risk of 10% or higher, type 2 diabetes mellitus, or type 1 diabetes mellitus with certain criteria. It is recommended to take statins at night, especially simvastatin, which has a shorter half-life than other statins. NICE recommends atorvastatin 20 mg for primary prevention and atorvastatin 80 mg for secondary prevention.

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      • Cardiovascular Health
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  • Question 55 - A 68-year-old man is worried about his blood pressure and has used his...

    Incorrect

    • A 68-year-old man is worried about his blood pressure and has used his wife's home blood pressure monitor. He found his blood pressure to be 154/96 mmHg. During his clinic visit, his blood pressure was measured twice, with readings of 156/98 mmHg and 154/98 mmHg. He has no significant medical history. To assess his overall health, you schedule him for a fasting glucose and lipid profile test. What is the best course of action to take?

      Your Answer:

      Correct Answer: Arrange ambulatory blood pressure monitoring

      Explanation:

      Prior to initiating treatment, NICE suggests verifying the diagnosis through ambulatory blood pressure monitoring.

      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 56 - A 42-year-old woman, who is a frequent IV drug user, presents with a...

    Incorrect

    • A 42-year-old woman, who is a frequent IV drug user, presents with a 2-week history of intermittent fever and fatigue. During examination, her temperature is 38.5 °C, heart rate 84 bpm and blood pressure 126/72 mmHg. A soft pansystolic murmur is detected along the right sternal margin and there is an area of tenderness and cellulitis in the left groin.
      What is the most suitable first step in managing this patient?

      Your Answer:

      Correct Answer: Emergency admission to the hospital

      Explanation:

      Emergency Management of Suspected Infective Endocarditis

      Suspected infective endocarditis is a life-threatening condition that requires urgent hospital admission. IV drug use is a major risk factor for this condition, which presents with fever and a new cardiac murmur. Oral therapy is not recommended due to concerns about efficacy, and IV therapy is preferred to ensure adequate dosing and administration. It is important to obtain blood cultures before starting antibiotics to isolate the causative organism. Ultrasound scan for a groin abscess is not necessary as it would not explain the pansystolic murmur on examination. Echocardiography is indicated but should not delay urgent treatment. Early diagnosis and management are crucial to prevent permanent cardiac damage.

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      • Cardiovascular Health
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  • Question 57 - 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

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      • Cardiovascular Health
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  • Question 58 - Which of the following patients is most likely to have their actual risk...

    Incorrect

    • Which of the following patients is most likely to have their actual risk of cardiovascular disease underestimated by QRISK2?

      Your Answer:

      Correct Answer: A 54-year-old man with a history of schizophrenia who takes olanzapine

      Explanation:

      Patients with a serious mental health disorder and those taking antipsychotics may have their cardiovascular disease risk underestimated by QRISK2.

      Management of Hyperlipidaemia: NICE Guidelines

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

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      • Cardiovascular Health
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  • Question 59 - 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.

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      • Cardiovascular Health
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  • Question 60 - Which one of the following statements regarding the metabolic syndrome is accurate? ...

    Incorrect

    • Which one of the following statements regarding the metabolic syndrome is accurate?

      Your Answer:

      Correct Answer: Decisions on cardiovascular risk factor modification should be made regardless of whether patients meet the criteria for metabolic syndrome

      Explanation:

      The determination of primary prevention measures for cardiovascular disease should rely on established methods and should not be influenced by the diagnosis of metabolic syndrome.

      Understanding Metabolic Syndrome

      Metabolic syndrome is a condition that has various definitions, but it is generally believed to be caused by insulin resistance. The American Heart Association and the International Diabetes Federation have similar criteria for diagnosing metabolic syndrome. According to these criteria, a person must have at least three of the following: elevated waist circumference, elevated triglycerides, reduced HDL, raised blood pressure, and raised fasting plasma glucose. The International Diabetes Federation also requires the presence of central obesity and any two of the other four factors. In 1999, the World Health Organization produced diagnostic criteria that required the presence of diabetes mellitus, impaired glucose tolerance, impaired fasting glucose or insulin resistance, and two of the following: high blood pressure, dyslipidemia, central obesity, and microalbuminuria. Other associated features of metabolic syndrome include raised uric acid levels, non-alcoholic fatty liver disease, and polycystic ovarian syndrome.

      Overall, metabolic syndrome is a complex condition that involves multiple factors and can have serious health consequences. It is important to understand the diagnostic criteria and associated features in order to identify and manage this condition effectively.

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      • Cardiovascular Health
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  • Question 61 - 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 62 - A 70-year-old woman presented with an ulcer over the left ankle, which had...

    Incorrect

    • A 70-year-old woman presented with an ulcer over the left ankle, which had developed over the previous nine months. She had a history of right deep vein thrombosis (DVT) five years previously.

      On examination she had a superficial slough-based ulcer, 6 cm in diameter, over the medial malleolus with no evidence of cellulitis.

      What investigation is required prior to the application of compression bandaging?

      Your Answer:

      Correct Answer: Bilateral lower limb arteriogram

      Explanation:

      Venous Ulceration and Arterial Disease

      Venous ulcerations are the most common type of ulcer affecting the lower extremities, often caused by venous insufficiency leading to venous congestion. Treatment involves controlling oedema, treating any infection, and compression, but compressive dressings or devices should not be used if arterial circulation is impaired. Therefore, it is crucial to identify any arterial disease, which can be done through the ankle-brachial pressure index. If indicated, a lower limb arteriogram may be necessary.

      In cases where there is no clinical sign of infection, ruling out arterial insufficiency is more important than a bacterial swab. If there is a suspicion of deep vein thrombosis, a duplex or venogram is necessary to determine the need for anticoagulation. By identifying and addressing both venous ulceration and arterial disease, proper treatment can be administered to promote healing and prevent further complications.

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      • Cardiovascular Health
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  • Question 63 - A 75-year-old man with a history of diabetes, hypertension, hypercholesterolaemia and previous myocardial...

    Incorrect

    • A 75-year-old man with a history of diabetes, hypertension, hypercholesterolaemia and previous myocardial infarction presents to his GP with intermittent abdominal pain that he has been experiencing for two months. The pain is dull in nature and radiates to his lower back. During examination, a pulsatile expansile mass is detected in the central abdomen. The patient had undergone an abdominal ultrasound 6 months ago which showed an abdominal aortic diameter of 5.1 cm. The GP repeats the ultrasound and refers the patient to the vascular clinic. The vascular surgeon reviews the patient's ultrasound report which shows no focal pancreatic, liver or gallbladder disease, trace free fluid, a 5.4 cm diameter abdominal aorta, no biliary duct dilation, and normal-sized and mildly echogenic kidneys.

      What aspect of the patient's medical history suggests that surgery may be necessary?

      Your Answer:

      Correct Answer: Abdominal pain

      Explanation:

      If a patient experiences abdominal pain, it is likely that they have a symptomatic AAA which poses a high risk of rupture. In such cases, surgical intervention, specifically endovascular repair (EVAR), is necessary rather than relying on medical treatment or observation. The abdominal aortic diameter must be greater than 5.5cm to be classified as high rupture risk, which is a close call. The presence of trace free fluid is generally considered normal. Conservative measures, such as quitting smoking, should be taken to address cardiovascular risk factors. An AAA’s velocity of growth should be monitored, and a high-risk AAA would only be indicated if there is an increase of more than 1 cm per year. Ultimately, the decision to proceed with elective surgery is a complex one that should be made in consultation with the patient and surgeon.

      Abdominal aortic aneurysm (AAA) is a condition that often develops without any symptoms. However, a ruptured AAA can be fatal, so it is important to screen patients for this condition. Screening involves a single abdominal ultrasound for males aged 65. The results of the screening are interpreted based on the width of the aorta. If the width is less than 3 cm, no further action is needed. If the width is between 3-4.4 cm, the patient should be rescanned every 12 months. If the width is between 4.5-5.4 cm, the patient should be rescanned every 3 months. If the width is 5.5 cm or greater, the patient should be referred to vascular surgery within 2 weeks for probable intervention.

      For patients with a low risk of rupture (asymptomatic, aortic diameter < 5.5cm), abdominal ultrasound surveillance should be conducted on the time-scales outlined above. Additionally, cardiovascular risk factors should be optimized, such as quitting smoking. For patients with a high risk of rupture (symptomatic, aortic diameter >=5.5cm or rapidly enlarging), referral to vascular surgery for probable intervention should occur within 2 weeks. Treatment options include elective endovascular repair (EVAR) or open repair if unsuitable. EVAR involves placing a stent into the abdominal aorta via the femoral artery to prevent blood from collecting in the aneurysm. However, a complication of EVAR is an endo-leak, where the stent fails to exclude blood from the aneurysm, and usually presents without symptoms on routine follow-up.

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      • Cardiovascular Health
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  • Question 64 - Mary comes to see you for a medication review. She is a 65-year-old...

    Incorrect

    • Mary comes to see you for a medication review. She is a 65-year-old woman, with a past medical history of chronic kidney disease stage 3, hypertension and gout. Her current medication are amlodipine 10 mg daily and allopurinol 100 mg daily. Her blood pressure today is 151/93 mmHg. A recent urine dip was normal and her blood results are shown in the table below.

      Na+ 137 mmol/L (135 - 145)
      K+ 4.7 mmol/L (3.5 - 5.0)
      Bicarbonate 27 mmol/L (22 - 29)
      Urea 5.6 mmol/L (2.0 - 7.0)
      Creatinine 130 µmol/L (55 - 120)
      eGFR 55 ml/min/1.73m2 (>90)

      What changes should you make to her medications?

      Your Answer:

      Correct Answer: Continue current medications, add ramipril

      Explanation:

      This patient is experiencing poorly controlled hypertension, despite being on the maximum dose of a calcium channel blocker. Additionally, he has established renal disease and his clinic blood pressure readings consistently exceed 140/90. To address this, it is recommended to add either an ACE inhibitor, an angiotensin 2 receptor blocker, or a thiazide-like diuretic to his current medication regimen. Simply relying on lifestyle modifications will not be sufficient to bring his blood pressure under control. Therefore, combination therapy with amlodipine should be continued.

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

      Lifestyle changes are also important in managing hypertension. Patients should aim for a low salt diet, reduce caffeine intake, stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more, and lose weight.

      Treatment for hypertension depends on the patient’s blood pressure classification. For stage 1 hypertension with ABPM/HBPM readings of 135/85 mmHg or higher, treatment is recommended for patients under 80 years old with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For stage 2 hypertension with ABPM/HBPM readings of 150/95 mmHg or higher, drug treatment is recommended regardless of age.

      The first-line treatment for patients under 55 years old or with a background of type 2 diabetes mellitus is an ACE inhibitor or angiotensin receptor blocker. Calcium channel blockers are recommended for patients over 55 years old or of black African or African-Caribbean origin. If a patient is already taking an ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker or thiazide-like diuretic can be added.

      If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, NICE recommends seeking expert advice or adding a fourth drug. Blood pressure targets vary depending on age, with a target of 140/90 mmHg for patients under 80 years old and 150/90 mmHg for patients over 80 years old. Direct renin inhibitors, such as Aliskiren, may be used in patients who are intolerant of other antihypertensive drugs, but their role is currently limited.

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      • Cardiovascular Health
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  • Question 65 - What is the significance of the class of compression stockings used in the...

    Incorrect

    • What is the significance of the class of compression stockings used in the treatment of chronic venous insufficiency?

      Your Answer:

      Correct Answer: The ankle pressure exerted by the stockings

      Explanation:

      Compression Stockings in Primary Care

      Compression stockings in primary care are classified according to the British standard, with Class 1 being light compression, Class 2 being medium compression, and Class 3 being high compression. The level of compression required depends on the condition being treated and should be the highest level that the individual can tolerate for that particular condition. It is important to note that the appropriate class of compression should be determined by a healthcare professional. Proper use of compression stockings can help improve circulation and reduce swelling in the legs.

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      • Cardiovascular Health
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  • Question 66 - You are reviewing a patient with hypertension who is 65 years old. As...

    Incorrect

    • You are reviewing a patient with hypertension who is 65 years old. As part of the review, you assess his 10 year cardiovascular disease risk and this is significant at 32%.

      This prompts discussion about the role of lipid lowering treatment in the primary prevention of cardiovascular disease. Following discussion, you both agree to start him on atorvastatin 20 mg daily. You can see his recent blood tests (FBC, U&Es, LFTs, TFTs and fasting glucose) are all normal.

      In terms of follow up blood testing, which of the following should be performed after starting the atorvastatin?

      Your Answer:

      Correct Answer: Full blood count every three months for the first 12 months after initiation

      Explanation:

      Monitoring Liver Function in Statin Therapy

      Before starting statin therapy, it is important to measure liver function. 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 still be used.

      Once statin therapy is initiated, liver function tests should be repeated within the first three months of treatment and then at 12 months. Additionally, liver function tests should be measured if a dose increase is made or if signs or symptoms of liver toxicity occur.

      It is crucial to monitor liver function in patients receiving statin therapy to ensure their safety and prevent potential liver damage. By following these guidelines, healthcare providers can ensure that patients receive the appropriate treatment while minimizing the risk of liver toxicity.

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      • Cardiovascular Health
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  • Question 67 - 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.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 68 - A worried mother brings her two-week-old baby to the clinic due to poor...

    Incorrect

    • A worried mother brings her two-week-old baby to the clinic due to poor feeding. The baby was born at 37 weeks gestation without any complications. No central cyanosis is observed, but the baby has a slightly elevated heart rate, rapid breathing, and high blood pressure in the upper extremities. Oxygen saturation levels are at 99% on air. Upon chest auscultation, a systolic murmur is heard loudest at the left sternal edge. Additionally, the baby has weak bilateral femoral pulses. What is the most probable underlying diagnosis?

      Your Answer:

      Correct Answer: Coarctation of the aorta

      Explanation:

      Coarctation of the Aorta: A Narrowing of the Descending Aorta

      Coarctation of the aorta is a congenital condition that affects the descending aorta, causing it to narrow. This condition is more common in males, despite its association with Turner’s syndrome. In infancy, coarctation of the aorta can lead to heart failure, while in adults, it can cause hypertension. Other features of this condition include radio-femoral delay, a mid systolic murmur that is maximal over the back, and an apical click from the aortic valve. Notching of the inferior border of the ribs, which is caused by collateral vessels, is not seen in young children. Coarctation of the aorta is often associated with other conditions, such as bicuspid aortic valve, berry aneurysms, and neurofibromatosis.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 69 - A 65-year-old man has a QRISK2 score of 14% and decides to start...

    Incorrect

    • A 65-year-old man has a QRISK2 score of 14% and decides to start taking atorvastatin 20 mg after discussing the benefits and risks with his doctor. His cholesterol levels are as follows:

      Total cholesterol: 5.6 mmol/l
      HDL cholesterol: 1.0 mmol/l
      LDL cholesterol: 3.4 mmol/l
      Triglyceride: 1.7 mmol/l

      When should he schedule a follow-up cholesterol test to assess the effectiveness of the statin?

      Your Answer:

      Correct Answer: 12 weeks

      Explanation:

      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 70 - An 80-year-old gentleman presents with an infective exacerbation of his bronchiectasis. Following clinical...

    Incorrect

    • An 80-year-old gentleman presents with an infective exacerbation of his bronchiectasis. Following clinical assessment you decide to treat him with a course of antibiotics. He has a past medical history of atrial fibrillation for which he takes lifelong warfarin. His notes state he is penicillin allergic and the patient confirms a history of a true allergy.

      You decide to prescribe a course of doxycycline, 200 mg on day 1 then 100 mg daily to complete a 14 day course.

      You can see his INR is very well managed and is consistently between 2.0 and 3.0 and he has been taking 3 mg and 4 mg on alternate days for the last six months without the need for any dose changes.

      What is the most appropriate management of his warfarin therapy during the treatment of this acute exacerbation?

      Your Answer:

      Correct Answer: Check his INR three to five days after starting the doxycycline

      Explanation:

      Managing Warfarin Patients on Antibiotics

      When a patient on warfarin requires antibiotics, it is a common clinical scenario that requires careful management. While there is no need to stop warfarin or switch to aspirin, it is important to monitor the patient’s INR levels closely. Typically, extra INR monitoring should be performed three to five days after starting the antibiotics to check for any potential impact on the INR. If necessary, a dosing change for warfarin may be needed.

      According to the British Committee for Standards in Haematology Guidelines for oral anticoagulation with warfarin (2011), it is important to follow specific recommendations for INR testing when a potential drug interaction occurs. By carefully monitoring INR levels and adjusting warfarin dosing as needed, healthcare providers can help ensure the safety and efficacy of treatment for patients on warfarin who require antibiotics.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 71 - A 65-year-old man has been diagnosed with hypertension and has a history of...

    Incorrect

    • A 65-year-old man has been diagnosed with hypertension and has a history of chronic heart failure due to alcoholic cardiomyopathy (NYHA class I). Which medication should be avoided due to contraindication?

      Your Answer:

      Correct Answer: Verapamil

      Explanation:

      Medications to Avoid in Patients with Heart Failure

      Patients with heart failure need to be cautious when taking certain medications as they may exacerbate their condition. Thiazolidinediones, such as pioglitazone, are contraindicated as they cause fluid retention. Verapamil should also be avoided due to its negative inotropic effect. NSAIDs and glucocorticoids should be used with caution as they can also cause fluid retention. However, low-dose aspirin is an exception as many patients with heart failure also have coexistent cardiovascular disease and the benefits of taking aspirin outweigh the risks. Class I antiarrhythmics, such as flecainide, should also be avoided as they have a negative inotropic and proarrhythmic effect. It is important for healthcare providers to be aware of these medications and their potential effects on patients with heart failure.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 72 - 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.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 73 - Which Antihypertensive medication is banned for use by professional athletes? ...

    Incorrect

    • Which Antihypertensive medication is banned for use by professional athletes?

      Your Answer:

      Correct Answer: Doxazosin

      Explanation:

      Prohibited Substances in Sports

      Beta-blockers and diuretics are among the substances prohibited in certain sports. In billiards and archery, the use of beta-blockers is not allowed as they can enhance performance by reducing anxiety and tremors. On the other hand, diuretics are generally prohibited as they can be used as masking agents to hide the presence of other banned substances. It is important to note that diuretics can be found in some combination products, such as Cozaar-Comp which contains hydrochlorothiazide. Athletes should be aware of the substances they are taking and ensure that they are not violating any anti-doping regulations.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 74 - 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.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 75 - You review a 59-year-old woman, who is worried about her risk of abdominal...

    Incorrect

    • You review a 59-year-old woman, who is worried about her risk of abdominal aortic aneurysm (AAA) due to her family history. She has a BMI of 28 kg/m² and a 20 pack-year smoking history. Her blood pressure in clinic is 136/88 mmHg. She is given a leaflet about AAA screening.

      What is accurate regarding AAA screening in this case?

      Your Answer:

      Correct Answer: He will be invited for one-off abdominal ultrasound at aged 65

      Explanation:

      At the age of 65, all males are invited for a screening to detect abdominal aortic aneurysm through a single abdominal ultrasound, irrespective of their risk factors. In case an aneurysm is identified, additional follow-up will be scheduled.

      Abdominal aortic aneurysm (AAA) is a condition that often develops without any symptoms. However, a ruptured AAA can be fatal, so it is important to screen patients for this condition. Screening involves a single abdominal ultrasound for males aged 65. The results of the screening are interpreted based on the width of the aorta. If the width is less than 3 cm, no further action is needed. If the width is between 3-4.4 cm, the patient should be rescanned every 12 months. If the width is between 4.5-5.4 cm, the patient should be rescanned every 3 months. If the width is 5.5 cm or greater, the patient should be referred to vascular surgery within 2 weeks for probable intervention.

      For patients with a low risk of rupture (asymptomatic, aortic diameter < 5.5cm), abdominal ultrasound surveillance should be conducted on the time-scales outlined above. Additionally, cardiovascular risk factors should be optimized, such as quitting smoking. For patients with a high risk of rupture (symptomatic, aortic diameter >=5.5cm or rapidly enlarging), referral to vascular surgery for probable intervention should occur within 2 weeks. Treatment options include elective endovascular repair (EVAR) or open repair if unsuitable. EVAR involves placing a stent into the abdominal aorta via the femoral artery to prevent blood from collecting in the aneurysm. However, a complication of EVAR is an endo-leak, where the stent fails to exclude blood from the aneurysm, and usually presents without symptoms on routine follow-up.

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      • Cardiovascular Health
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  • Question 76 - What factors in a patient's medical record could potentially elevate natriuretic peptide levels...

    Incorrect

    • What factors in a patient's medical record could potentially elevate natriuretic peptide levels (such as NT-proBNP) that are utilized to evaluate possible heart failure?

      Your Answer:

      Correct Answer: Chronic obstructive pulmonary disease

      Explanation:

      Natriuretic Peptide Levels in Heart Failure Assessment

      Natriuretic peptide levels, specifically NT-ProBNP levels, are utilized in the evaluation of heart failure to determine the likelihood of diagnosis and the urgency of any necessary referral. These levels can be influenced by various factors.

      Factors that can decrease natriuretic peptide levels include a body mass index over 35 kg/m2, diuretics, ACE inhibitors, angiotensin receptor blockers, beta blockers, and aldosterone antagonists. On the other hand, factors that can increase natriuretic peptide levels include age over 70, left ventricular hypertrophy, myocardial ischaemia, tachycardia, right ventricular overload, hypoxia, pulmonary hypertension, pulmonary embolism, chronic kidney disease with an eGFR less than 60 mL/min/1.73m2, sepsis, COPD, diabetes mellitus, and liver cirrhosis.

      It is important to consider these factors when interpreting natriuretic peptide levels in the assessment of heart failure.

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      • Cardiovascular Health
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  • Question 77 - A 65-year-old man visits your GP practice, who is typically healthy. He had...

    Incorrect

    • A 65-year-old man visits your GP practice, who is typically healthy. He had come to see you a few weeks ago with a viral infection, during which you recorded his clinic blood pressure as 168/105 mmHg. You have since arranged for ambulatory blood pressure monitoring (ABPM), blood tests, urine dip, an ECG, and are now reviewing the results with him.

      The ABPM average shows his blood pressure to be 157/100 mmHg. You have also conducted blood tests to check his plasma glucose, electrolytes, creatinine, estimated glomerular filtration rate, serum total cholesterol, and HDL cholesterol. His renal function and glucose levels are normal, and a urine dip for protein and ECG are also normal. Upon checking the back of his eyes, you find that the fundi are normal. His QRisk is calculated to be 28%.

      You discuss potential treatment options with the patient. What should be included in your management plan?

      Your Answer:

      Correct Answer:

      Explanation:

      As a primary prevention measure for cardiovascular disease, it is recommended to discuss and suggest statin therapy to the patient. The target for clinic blood pressure should be less than 140/90 mmHg and less than 135/85 mmHg for ambulatory blood pressure monitoring. To achieve this, amlodipine and lifestyle advice should be offered along with atorvastatin.

      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 78 - 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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  • Question 79 - A 65-year-old lady presents with a brief history of sudden onset severe left...

    Incorrect

    • A 65-year-old lady presents with a brief history of sudden onset severe left lower limb pain lasting for three hours. The pain started while she was at rest and there was no history of injury or any previous leg or calf pain.
      Upon examination, her pulse rate is irregular and measures 92 bpm. The left lower limb is cold and immobile with decreased sensation. No pulses can be felt from the level of the femoral pulse downwards in the left leg, but all pulses are palpable on the right. There are no abdominal masses or bruits, and chest auscultation is normal.
      What is the probable diagnosis?

      Your Answer:

      Correct Answer: Sciatica

      Explanation:

      Acute Limb Ischaemia: Causes and Symptoms

      Acute limb ischaemia is a condition characterized by a painful, paralysed, and pulseless limb that feels perishingly cold with paraesthesia. This condition is usually caused by either an embolus or thrombotic occlusion, which can occur on the background of intermittent claudication (chronic limb ischaemia). In most cases, the likely cause of acute limb ischaemia is an embolism secondary to atrial fibrillation. Other sources of emboli include defective heart valves, cardiac mural thrombi, and thrombus from within an aortic aneurysm.

      If a patient presents with a painful, paralysed, and pulseless limb, an echocardiogram, abdominal ultrasound, and duplex of proximal limb vessels are indicated. These tests can help identify the underlying cause of the condition. It is important to note that acute limb ischaemia is a medical emergency that requires immediate attention. Delayed treatment can lead to irreversible tissue damage and even limb loss.

      In summary, acute limb ischaemia is a serious condition that requires prompt diagnosis and treatment. Patients with this condition should seek medical attention immediately to prevent irreversible tissue damage and limb loss.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 80 - A 70-year-old woman is prescribed amlodipine 5mg once daily for hypertension. She has...

    Incorrect

    • A 70-year-old woman is prescribed amlodipine 5mg once daily for hypertension. She has no significant medical history and her routine blood tests (including fasting glucose) and ECG were unremarkable.

      What is the recommended target blood pressure for her while on amlodipine treatment?

      Your Answer:

      Correct Answer:

      Explanation:

      The recommended blood pressure target for individuals under 80 years old during a clinic reading is 140/90 mmHg. However, the Quality and Outcomes Framework (QOF) indicator for GPs practicing in England specifies a slightly higher target of below 150/90 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
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  • Question 81 - A 65-year-old gentleman, with stable schizophrenia and a penicillin allergy, had a routine...

    Incorrect

    • A 65-year-old gentleman, with stable schizophrenia and a penicillin allergy, had a routine ECG which showed a QTc interval of 420 ms. He takes oral quetiapine regularly. He was started on a course of clarithromycin for a recently suspected tonsillitis and has now recovered. He reported no new symptoms and was otherwise well. Blood tests including electrolytes were normal.

      Which is the SINGLE MOST appropriate NEXT management step?

      Your Answer:

      Correct Answer: Discuss with the on-call psychiatry team for advice

      Explanation:

      Normal QTc Interval in Patient Taking Quetiapine and Clarithromycin

      The normal values for QTc are < 440 ms in men and <470 ms in women. It is important to monitor the QTc interval in patients taking medications such as quetiapine and clarithromycin, which are known to increase the QTc interval. In this scenario, an ECG was performed and the QTc interval was found to be normal. Therefore, no intervention is necessary at this time. It is important to continue monitoring the patient's QTc interval throughout their treatment with these medications. Proper monitoring can help prevent potentially life-threatening arrhythmias.

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      • Cardiovascular Health
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  • Question 82 - A 62-year-old woman has been visiting the practice nurse for a few weeks...

    Incorrect

    • A 62-year-old woman has been visiting the practice nurse for a few weeks for blood pressure (BP) checks. Her results have shown significant variability. She presents you with a diary of home readings that the nurse has instructed her to take twice daily over the past two weeks. Her average BP based on these readings is 135/80 mmHg. Her BP today in the clinic is 162/102 mmHg, and the nurse has recorded similar levels on the last two visits. She doesn't want to take medication for her BP. She has no other medical conditions.
      What is the most suitable course of action? Choose ONE option only.

      Your Answer:

      Correct Answer: Accept the home blood pressure (BP) readings and diagnose white-coat hypertension

      Explanation:

      Managing White-Coat Hypertension with Home Blood Pressure Monitoring

      According to current NICE guidance, hypertension should be diagnosed in patients with a clinic BP of 140/90 mmHg or greater and either average daily ambulatory BP monitoring (ABPM) or home BP monitoring (HBPM) readings of greater than 135/85. However, if a patient’s home readings are within normal range, their elevated clinic BP is likely due to white-coat hypertension. In such cases, further assessment with ABPM is unnecessary. Monthly BP reviews with the practice nurse are also unnecessary if HBPM readings are normal. Treatment is not recommended based on clinic readings alone, and specialist referral is not needed if HBPM readings are within normal range. Home blood pressure monitoring can effectively manage white-coat hypertension.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 83 - A 58-year-old male with stable angina complains of muscle aches and pains. He...

    Incorrect

    • A 58-year-old male with stable angina complains of muscle aches and pains. He has been on simvastatin 40 mg daily, atenolol 50 mg daily, and aspirin 75 mg daily for two years. He was recently hospitalized for acute coronary syndrome and additional therapies were added. His CPK concentration is 820 IU/L (50-200). What is the most probable cause of his statin-related myopathy?

      Your Answer:

      Correct Answer: Omega-3 fatty acids

      Explanation:

      Statin-Associated Myopathy and Drug Interactions

      Statin-associated myopathy is a potential side effect that affects up to 5% of individuals taking statins. This condition can be exacerbated by the co-prescription of certain drugs, including calcium channel blockers, macrolide antibiotics, fibrates, amiodarone, and grapefruit juice. Even patients who tolerate statins well may experience myopathy or rhabdomyolysis when these agents are added to their treatment regimen.

      It is important for healthcare providers to be aware of these potential drug interactions and to monitor patients closely for signs of myopathy. Additionally, NICE guidance on Myocardial infarction: secondary prevention (NG185) advises against the use of omega-3 capsules to prevent another MI. By staying informed and following evidence-based guidelines, healthcare providers can help ensure the safety and well-being of their patients.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 84 - You assess a 79-year-old male patient's hypertensive treatment and find that his current...

    Incorrect

    • You assess a 79-year-old male patient's hypertensive treatment and find that his current medication regimen of losartan and amlodipine is not effectively controlling his blood pressure. What would be the most suitable course of action, assuming there are no relevant contraindications?

      Your Answer:

      Correct Answer: Add indapamide MR 1.5mg od

      Explanation:

      For poorly controlled hypertension in a patient already taking an ACE inhibitor and a calcium channel blocker, it is recommended to add a thiazide-like diuretic. However, NICE advises against using bendroflumethiazide and suggests alternative options. It is important to note that patients who are already taking bendroflumethiazide should not be switched to another thiazide-type diuretic. In this case, the patient is currently taking losartan, which is an angiotensin 2 receptor blocker. This may be due to previous issues with ACE inhibitor therapy, such as a dry cough. It is generally not recommended for patients to take both an ACE inhibitor and an A2RB simultaneously.

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

      Lifestyle changes are also important in managing hypertension. Patients should aim for a low salt diet, reduce caffeine intake, stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more, and lose weight.

      Treatment for hypertension depends on the patient’s blood pressure classification. For stage 1 hypertension with ABPM/HBPM readings of 135/85 mmHg or higher, treatment is recommended for patients under 80 years old with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For stage 2 hypertension with ABPM/HBPM readings of 150/95 mmHg or higher, drug treatment is recommended regardless of age.

      The first-line treatment for patients under 55 years old or with a background of type 2 diabetes mellitus is an ACE inhibitor or angiotensin receptor blocker. Calcium channel blockers are recommended for patients over 55 years old or of black African or African-Caribbean origin. If a patient is already taking an ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker or thiazide-like diuretic can be added.

      If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, NICE recommends seeking expert advice or adding a fourth drug. Blood pressure targets vary depending on age, with a target of 140/90 mmHg for patients under 80 years old and 150/90 mmHg for patients over 80 years old. Direct renin inhibitors, such as Aliskiren, may be used in patients who are intolerant of other antihypertensive drugs, but their role is currently limited.

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      • Cardiovascular Health
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  • Question 85 - A 55-year-old male with diabetes is diagnosed with hypertension.

    You discuss starting treatment and...

    Incorrect

    • A 55-year-old male with diabetes is diagnosed with hypertension.

      You discuss starting treatment and initiate ramipril at a dose of 1.25 mg daily. His recent blood test results show normal full blood count, renal function, liver function, thyroid function and fasting glucose.

      His other medications are: metformin 500 mg TDS, gliclazide 80 mg OD and simvastatin 40 mg ON.

      What blood test monitoring should next be performed?

      Your Answer:

      Correct Answer: Repeat renal function in 7-14 days

      Explanation:

      Renal Function Monitoring for ACE Inhibitor Treatment

      Renal function monitoring is crucial before initiating treatment with an ACE inhibitor and one to two weeks after initiation or any subsequent dose increase, according to NICE recommendations. Although ACE inhibitors have a role in managing chronic kidney disease, they can also cause impairment of renal function that may be progressive. The concomitant use of NSAIDs and potassium-sparing diuretics increases the risks of renal side effects and hyperkalaemia, respectively.

      In patients with bilateral renal stenosis who are given ACE inhibitors, marked renal failure can occur. Therefore, if there is a significant deterioration in renal function as a result of ACE inhibition, a specialist should be involved. It is important to monitor renal function regularly to ensure the safe and effective use of ACE inhibitors in the management of various conditions.

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      • Cardiovascular Health
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  • Question 86 - Which one of the following statements regarding B-type natriuretic peptide is incorrect? ...

    Incorrect

    • Which one of the following statements regarding B-type natriuretic peptide is incorrect?

      Your Answer:

      Correct Answer: The positive predictive value of BNP is greater than the negative predictive value

      Explanation:

      The negative predictive value of BNP for ventricular dysfunction is good, but its positive predictive value is poor.

      B-type natriuretic peptide (BNP) is a hormone that is primarily produced by the left ventricular myocardium in response to strain. Although heart failure is the most common cause of elevated BNP levels, any condition that causes left ventricular dysfunction, such as myocardial ischemia or valvular disease, may also raise levels. In patients with chronic kidney disease, reduced excretion may also lead to elevated BNP levels. Conversely, treatment with ACE inhibitors, angiotensin-2 receptor blockers, and diuretics can lower BNP levels.

      BNP has several effects, including vasodilation, diuresis, natriuresis, and suppression of both sympathetic tone and the renin-angiotensin-aldosterone system. Clinically, BNP is useful in diagnosing patients with acute dyspnea. A low concentration of BNP (<100 pg/mL) makes a diagnosis of heart failure unlikely, but elevated levels should prompt further investigation to confirm the diagnosis. Currently, NICE recommends BNP as a helpful test to rule out a diagnosis of heart failure. In patients with chronic heart failure, initial evidence suggests that BNP is an extremely useful marker of prognosis and can guide treatment. However, BNP is not currently recommended for population screening for cardiac dysfunction.

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      • Cardiovascular Health
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  • Question 87 - Sophie is a 82-year-old woman with type 2 diabetes and hypertension. She visits...

    Incorrect

    • Sophie is a 82-year-old woman with type 2 diabetes and hypertension. She visits her GP after experiencing a 10-minute episode where she couldn't move her left arm. Her arm function has since returned to normal and her neurological examination is unremarkable.

      What is the most accurate diagnosis for Sophie based on the given information?

      Your Answer:

      Correct Answer: Neurological dysfunction caused by a transient episode of brain ischaemia

      Explanation:

      The definition of a TIA has been updated to focus on the affected tissue rather than the duration of symptoms. It is now defined as a temporary episode of neurological dysfunction resulting from restricted blood flow to the brain, spinal cord, or retina, without causing acute tissue damage. An ischaemic stroke, on the other hand, is characterized by neurological dysfunction caused by cerebral infarction, while multiple sclerosis is defined by neurological dysfunction caused by demyelination. Finally, a functional neurological disorder is characterized by transient symptoms of psychological origin.

      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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  • Question 88 - A 68-year-old man with a history of cardiovascular disease presents with worsening shortness...

    Incorrect

    • A 68-year-old man with a history of cardiovascular disease presents with worsening shortness of breath on exertion. You suspect left ventricular failure. Identify the single test that, if normal, would make the diagnosis of heart failure highly unlikely.

      Your Answer:

      Correct Answer: An ECG

      Explanation:

      Investigations for Suspected Heart Failure: Importance of ECG and Natriuretic Peptides

      When a patient is suspected of having heart failure, several investigations are recommended to confirm the diagnosis and determine the underlying cause. Routine blood tests, including full blood count, urea and electrolytes, liver function tests, thyroid function tests, and blood glucose, are typically performed. However, the results of these tests alone are not sufficient to diagnose heart failure.

      An electrocardiogram (ECG) is also commonly performed, although its predictive value for heart failure is limited. A normal ECG can make left ventricular systolic dysfunction unlikely, with a negative predictive value of 98%. On the other hand, an abnormal ECG may indicate the need for further testing, such as echocardiography.

      Serum natriuretic peptides, which are released by the heart in response to increased pressure or volume, can also be helpful in diagnosing heart failure. If these levels are normal, the diagnosis of heart failure is less likely. However, this test is not always available or necessary in the initial investigation.

      A chest x-ray can provide supportive evidence for heart failure and rule out other potential causes of breathlessness. It is important to note that oxygen saturation may be normal in heart failure, so this alone cannot be used to rule out the condition.

      Echocardiography is the gold standard for diagnosing heart failure and determining the underlying cause. It is recommended in patients who have either a raised natriuretic peptide level or an abnormal ECG. By providing detailed images of the heart’s structure and function, echocardiography can help guide treatment decisions and improve outcomes for patients with heart failure.

      In summary, a combination of tests is necessary to diagnose heart failure and determine the best course of treatment. The ECG and natriuretic peptides can provide important clues, but echocardiography is essential for confirming the diagnosis and identifying the underlying cause.

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      • Cardiovascular Health
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  • Question 89 - A 55-year-old caucasian man presents to his GP with the results of 7...

    Incorrect

    • A 55-year-old caucasian man presents to his GP with the results of 7 days of home blood pressure monitoring (HBPM) he was advised to complete following a random clinic blood pressure of 144/92 mmHg. His HBPM is 138/88 mmHg. Baseline investigations show no evidence of end-organ damage. He is a current smoker. His QRISK3 score is calculated to be 11.2%. He has no known medication allergies. Lifestyle and smoking cessation advice is provided. What is the most appropriate treatment option?

      Your Answer:

      Correct Answer: Atorvastatin and ramipril

      Explanation:

      The current prescription of Atorvastatin alone is not sufficient for this patient. In addition to lipid-lowering therapy, he should also be offered an antihypertensive agent. However, it is important to note that due to his age and ethnicity, he should first be offered an ACE and/or angiotensin-II receptor antagonist. If he doesn’t have type 2 diabetes and is aged 55 years or over, or if he is of black African or African-Caribbean family origin and doesn’t have type 2 diabetes (of any age), calcium-channel blockers may be considered as the first-line antihypertensive agent. It is not appropriate to suggest that no treatment is required.

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

      Lifestyle changes are also important in managing hypertension. Patients should aim for a low salt diet, reduce caffeine intake, stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more, and lose weight.

      Treatment for hypertension depends on the patient’s blood pressure classification. For stage 1 hypertension with ABPM/HBPM readings of 135/85 mmHg or higher, treatment is recommended for patients under 80 years old with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For stage 2 hypertension with ABPM/HBPM readings of 150/95 mmHg or higher, drug treatment is recommended regardless of age.

      The first-line treatment for patients under 55 years old or with a background of type 2 diabetes mellitus is an ACE inhibitor or angiotensin receptor blocker. Calcium channel blockers are recommended for patients over 55 years old or of black African or African-Caribbean origin. If a patient is already taking an ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker or thiazide-like diuretic can be added.

      If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, NICE recommends seeking expert advice or adding a fourth drug. Blood pressure targets vary depending on age, with a target of 140/90 mmHg for patients under 80 years old and 150/90 mmHg for patients over 80 years old. Direct renin inhibitors, such as Aliskiren, may be used in patients who are intolerant of other antihypertensive drugs, but their role is currently limited.

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      • Cardiovascular Health
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  • Question 90 - An 80-year-old man has been diagnosed with atrial fibrillation during his annual hypertension...

    Incorrect

    • An 80-year-old man has been diagnosed with atrial fibrillation during his annual hypertension review after an irregular pulse was detected. He has no bleeding risk factors, no other co-morbidities, and a CHA2DS2VASc score of 3. He consents to starting medication for stroke prevention. What is the recommended first-line treatment for stroke prevention in this case?

      Your Answer:

      Correct Answer: Edoxaban

      Explanation:

      When it comes to reducing the risk of stroke in individuals with atrial fibrillation and a CHA2DS2VASc score of 2 or higher, the first-line option should be anticoagulation with a direct-acting oral anticoagulant (DOAC) such as apixaban, dabigatran, edoxaban, or rivaroxaban. In a primary care setting, it is important to use the CHA2DS2VASc assessment tool to evaluate the person’s stroke risk, as well as assess the risk of bleeding and work to mitigate any current risk factors such as uncontrolled hypertension, concurrent medication, harmful alcohol consumption, and reversible causes of anemia.

      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 91 - A 56-year-old man is admitted with ST elevation myocardial infarction and treated with...

    Incorrect

    • A 56-year-old man is admitted with ST elevation myocardial infarction and treated with thrombolysis but no angioplasty. What guidance should he receive regarding driving?

      Your Answer:

      Correct Answer: Cannot drive for 4 weeks

      Explanation:

      DVLA guidance following a heart attack – refrain from driving for a period of 4 weeks.

      DVLA Guidelines for Cardiovascular Disorders and Driving

      The DVLA has specific guidelines for individuals with cardiovascular disorders who wish to drive a car or motorcycle. For those with hypertension, driving is permitted unless the treatment causes unacceptable side effects, and there is no need to notify the DVLA. However, if the individual has Group 2 Entitlement, they will be disqualified from driving if their resting blood pressure consistently measures 180 mmHg systolic or more and/or 100 mm Hg diastolic or more.

      Individuals who have undergone elective angioplasty must refrain from driving for one week, while those who have undergone CABG or acute coronary syndrome must wait four weeks before driving. If an individual experiences angina symptoms at rest or while driving, they must cease driving altogether. Pacemaker insertion requires a one-week break from driving, while implantable cardioverter-defibrillator (ICD) implantation results in a six-month driving ban if implanted for sustained ventricular arrhythmia. If implanted prophylactically, the individual must cease driving for one month, and Group 2 drivers are permanently barred from driving with an ICD.

      Successful catheter ablation for an arrhythmia requires a two-day break from driving, while an aortic aneurysm of 6 cm or more must be reported to the DVLA. Licensing will be permitted subject to annual review, but an aortic diameter of 6.5 cm or more disqualifies patients from driving. Finally, individuals who have undergone a heart transplant must refrain from driving for six weeks, but there is no need to notify the DVLA.

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      • Cardiovascular Health
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  • Question 92 - What is the correct option for measuring blood pressure using either an automated...

    Incorrect

    • What is the correct option for measuring blood pressure using either an automated machine or a manual method?

      Your Answer:

      Correct Answer: Patients should rest for 5 minutes before the measurement is taken

      Explanation:

      Guidelines for Measuring Blood Pressure

      When measuring blood pressure, it is important to follow certain guidelines to ensure accurate readings. The patient should be seated for at least five minutes, in a relaxed state without moving or speaking. Blood pressure should be recorded three times, initially testing in both arms. If there is a sustained difference of more than 20 mmHg, use the arm with the higher reading for subsequent measurements. The arm must be supported at the level of the heart.

      If the blood pressure is 140/90 mmHg or higher, up to three readings should be taken, and the lower of the last two recorded as the blood pressure. It is important to note that automated devices may not measure blood pressure accurately if there is pulse irregularity, such as atrial fibrillation. In such cases, blood pressure should be measured manually using direct auscultation over the brachial artery. By following these guidelines, healthcare professionals can ensure accurate blood pressure readings for their patients.

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      • Cardiovascular Health
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  • Question 93 - After sending several invitations, 58-year-old Mrs. Johnson attends the clinic for her medication...

    Incorrect

    • After sending several invitations, 58-year-old Mrs. Johnson attends the clinic for her medication review. She has not been to the clinic for over a year due to her busy work schedule. Mrs. Johnson is currently taking allopurinol 200 mg, candesartan 8mg, indapamide 2.5mg, omeprazole 20 mg, and salbutamol inhaler as required.

      During her visit, her blood pressure is measured several times and is found to be 168/96 mmHg. Mrs. Johnson reports taking her medications almost every day, but her blood pressure is still high. As per NICE guidelines, which class of antihypertensive medication should be added to her current treatment plan?

      Your Answer:

      Correct Answer: Calcium channel blocker

      Explanation:

      For a patient with poorly controlled hypertension who is already taking an ACE inhibitor and a thiazide diuretic, the recommended next step would be to add a calcium channel blocker. This is because adding another ACE inhibitor would not be appropriate, and beta-blockers may be contraindicated if the patient has asthma. Loop diuretics are not typically used as a treatment for hypertension.

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

      Lifestyle changes are also important in managing hypertension. Patients should aim for a low salt diet, reduce caffeine intake, stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more, and lose weight.

      Treatment for hypertension depends on the patient’s blood pressure classification. For stage 1 hypertension with ABPM/HBPM readings of 135/85 mmHg or higher, treatment is recommended for patients under 80 years old with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For stage 2 hypertension with ABPM/HBPM readings of 150/95 mmHg or higher, drug treatment is recommended regardless of age.

      The first-line treatment for patients under 55 years old or with a background of type 2 diabetes mellitus is an ACE inhibitor or angiotensin receptor blocker. Calcium channel blockers are recommended for patients over 55 years old or of black African or African-Caribbean origin. If a patient is already taking an ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker or thiazide-like diuretic can be added.

      If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, NICE recommends seeking expert advice or adding a fourth drug. Blood pressure targets vary depending on age, with a target of 140/90 mmHg for patients under 80 years old and 150/90 mmHg for patients over 80 years old. Direct renin inhibitors, such as Aliskiren, may be used in patients who are intolerant of other antihypertensive drugs, but their role is currently limited.

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      • Cardiovascular Health
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  • Question 94 - A 45-year-old man presents for a follow-up of his hypertension. He is of...

    Incorrect

    • A 45-year-old man presents for a follow-up of his hypertension. He is of Caucasian descent. He was diagnosed with essential hypertension six months ago and was prescribed ramipril, which has been increased to 10 mg daily. He also has a medical history of hypercholesterolemia and gout, and he takes atorvastatin 20 mg once nightly.

      He provides a set of home blood pressure readings with an average of 140/95 mmHg.

      What is the best course of action for managing his condition?

      Your Answer:

      Correct Answer: Add amlodipine

      Explanation:

      For a patient with poorly controlled hypertension who is already taking an ACE inhibitor, the recommended medication to add would be either a calcium channel blocker or a thiazide-like diuretic. In this case, since the patient has a history of gout, a calcium channel blocker like amlodipine would be the most appropriate choice. Losartan, an A2RB drug, should not be used in combination with ACE inhibitors. The maximum daily dose of ramipril is 10 mg. The target home readings for this patient would be less than 135/85 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.

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      • Cardiovascular Health
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  • Question 95 - 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 96 - Barbara is a 57-year-old woman who has come to see you after high...

    Incorrect

    • Barbara is a 57-year-old woman who has come to see you after high blood pressure readings during a routine check with the nurse.

      You take two blood pressure readings, the lower of which is 190/126 mmHg.

      Barbara has no headache or chest pain. On examination of her cardiovascular and neurological systems, there are no abnormalities. Fundoscopy is normal.

      What is the most crucial next step to take?

      Your Answer:

      Correct Answer: Urgently carry out investigations for target organ damage including ECG, urine dip and blood tests

      Explanation:

      If Cynthia’s blood pressure is equal to or greater than 180/120 mmHg and she has no worrying signs, the first step is to urgently investigate for any damage to her organs.

      According to NICE guidelines, if a person has severe hypertension but no symptoms or signs requiring immediate referral, investigations for target organ damage should be carried out as soon as possible. Since Cynthia has no such symptoms or signs, investigating for target organ damage is the correct option.

      If target organ damage is found, antihypertensive drug treatment should be considered immediately, without waiting for the results of ABPM or HBPM. Therefore, prescribing a calcium channel blocker is not the correct answer as assessing for organ damage is the more urgent priority.

      Repeating clinic blood pressure measurement within 7 days at this stage would not be helpful in guiding further management, as assessing for target organ damage is the priority. NICE recommends repeating clinic blood pressure measurement within 7 days only if no target organ damage is identified.

      Assessing for target organ damage involves testing for protein and haematuria in the urine, measuring HbA1C, electrolytes, creatinine, estimated glomerular filtration rate, total cholesterol, and HDL cholesterol in the blood, examining the fundi for hypertensive retinopathy, and performing a 12-lead electrocardiograph.

      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 97 - A 68-year-old man with lung cancer is diagnosed with deep vein thrombosis. He...

    Incorrect

    • A 68-year-old man with lung cancer is diagnosed with deep vein thrombosis. He is seen in the hospital clinic and prescribed a direct oral anticoagulant (DOAC). What would be the best course of treatment?

      Your Answer:

      Correct Answer: Continue on the DOAC for 3-6 months

      Explanation:

      In 2020, NICE revised their guidance to suggest the use of DOACs for individuals with active cancer who have VTE. Prior to this, low molecular weight heparin was the recommended treatment.

      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
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  • Question 98 - For which patient is it necessary to utilize a cardiovascular risk assessment tool...

    Incorrect

    • For which patient is it necessary to utilize a cardiovascular risk assessment tool (such as QRISK) in order to ascertain their likelihood of developing cardiovascular disease (CVD)?

      Your Answer:

      Correct Answer: A 45-year-old man with type 1 diabetes with a HbA1c of 48 mmol/mol and no nephropathy or microalbuminuria

      Explanation:

      High Risk Patients for Cardiovascular Disease

      Certain patients are automatically considered at high risk for cardiovascular disease (CVD) and do not require the use of a CVD risk assessment tool such as QRISK2. These high-risk patients include those with pre-existing CVD, those aged 85 and above, those with an eGFR <60 ml/min/1.73m2 and/or albuminuria, those with familial hypercholesterolaemia or other inherited lipid disorders, and those with type 1 diabetes who are over 40 years old, have a history of diabetes for at least 10 years, have established nephropathy, or have other CVD risk factors. However, for patients with a BMI of 38, a CVD risk assessment tool should be used. It is important to note that for patients with a BMI higher than 40 kg/m2, their risk may be underestimated by standard CVD risk assessment tools. By identifying high-risk patients, healthcare providers can take appropriate measures to prevent and manage CVD.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 99 - A 75-year-old patient comes in for her regular heart failure check-up. Upon reviewing...

    Incorrect

    • A 75-year-old patient comes in for her regular heart failure check-up. Upon reviewing her echocardiogram, it is found that she has a reduced ejection fraction of 40% and no significant valve disease. Her blood pressure is measured at 160/90 mmHg during the visit. There is no indication of fluid overload, and her weight has remained stable. The patient is currently taking bisoprolol and furosemide.

      After reviewing her blood work, it is discovered that her potassium levels are slightly elevated at 5.3 mmol/L. What would be the most appropriate course of action for management?

      Your Answer:

      Correct Answer: Seek specialist advice before starting an ACE inhibitor owing to the raised potassium

      Explanation:

      Before initiating an ACE inhibitor in patients with heart failure with a reduced ejection fraction, it is recommended to seek specialist advice if the potassium level is above 5 mmol/L. The current NICE CKS guidance suggests starting bisoprolol and ramipril for such patients. However, if the potassium level is high, it is advisable to repeat the urea and electrolytes in 2-3 weeks and seek specialist advice before starting an ACE inhibitor. As the patient is asymptomatic, increasing the dose of furosemide would not be beneficial. There is no need for same-day medical assessment as the patient is currently stable. Although bendroflumethiazide may be suitable for hypertension, NICE CKS recommends ACEi for heart failure treatment.

      Angiotensin-converting enzyme (ACE) inhibitors are commonly used as the first-line treatment for hypertension and heart failure in younger patients. However, they may not be as effective in treating hypertensive Afro-Caribbean patients. ACE inhibitors are also used to treat diabetic nephropathy and prevent ischaemic heart disease. These drugs work by inhibiting the conversion of angiotensin I to angiotensin II and are metabolized in the liver.

      While ACE inhibitors are generally well-tolerated, they can cause side effects such as cough, angioedema, hyperkalaemia, and first-dose hypotension. Patients with certain conditions, such as renovascular disease, aortic stenosis, or hereditary or idiopathic angioedema, should use ACE inhibitors with caution or avoid them altogether. Pregnant and breastfeeding women should also avoid these drugs.

      Patients taking high-dose diuretics may be at increased risk of hypotension when using ACE inhibitors. Therefore, it is important to monitor urea and electrolyte levels before and after starting treatment, as well as any changes in creatinine and potassium levels. Acceptable changes include a 30% increase in serum creatinine from baseline and an increase in potassium up to 5.5 mmol/l. Patients with undiagnosed bilateral renal artery stenosis may experience significant renal impairment when using ACE inhibitors.

      The current NICE guidelines recommend using a flow chart to manage hypertension, with ACE inhibitors as the first-line treatment for patients under 55 years old. However, individual patient factors and comorbidities should be taken into account when deciding on the best treatment plan.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 100 - A 50-year-old man with high blood pressure visits his GP for a check-up....

    Incorrect

    • A 50-year-old man with high blood pressure visits his GP for a check-up. His blood pressure has been consistently high, with a reading of 154/82 during his last visit. The GP arranged for ambulatory blood pressure monitoring, which showed an average daytime blood pressure of 140/88 mmHg. Despite being on the highest dose of ramipril, his blood pressure remains elevated. What would be the most suitable second-line medication to add?

      Your Answer:

      Correct Answer: Indapamide

      Explanation:

      In cases of poorly controlled hypertension where the patient is already taking an ACE inhibitor, the updated NICE guidelines (2019) recommend adding a calcium-channel blocker (CCB) or a thiazide-like diuretic like indapamide as the next step. If the patient’s potassium levels are greater than 4.5 mmol/L, bisoprolol and doxazosin can be added as 4th line agents for those with resistant hypertension. On the other hand, spironolactone can be added as a 4th line agent when potassium levels are lower than 4.5 mmol/L.

      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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