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  • Question 1 - An 80-year-old man who is currently taking warfarin inquires about the feasibility of...

    Correct

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

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

      Your Answer: Mechanical heart valve

      Explanation:

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

      Dabigatran: An Oral Anticoagulant with Two Main Indications

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

    • This question is part of the following fields:

      • Cardiovascular Health
      25.7
      Seconds
  • Question 2 - 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
      44.4
      Seconds
  • Question 3 - 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: The risk of stent thrombosis is reduced

      Correct Answer: The risk of re-stenosis is reduced

      Explanation:

      Understanding Drug-Eluting Stents and Antiplatelet Therapy for Coronary Stents

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

    • This question is part of the following fields:

      • Cardiovascular Health
      61.6
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  • Question 4 - A 50-year-old man presents for a routine check-up and inquires about the benefits...

    Correct

    • A 50-year-old man presents for a routine check-up and inquires about the benefits and drawbacks of taking daily aspirin. He has normal blood pressure and his cholesterol and glucose levels are within normal limits.
      What is the one accurate statement regarding the advantages and disadvantages of aspirin in primary prevention?

      Your Answer: Aspirin use in primary prevention reduces risk of non-fatal myocardial infarction

      Explanation:

      The Pros and Cons of Aspirin in Primary Prevention

      Aspirin has been found to reduce the risk of myocardial infarction in primary prevention studies. However, this benefit is counterbalanced by an increased risk of gastrointestinal bleeding, which is highest in the first 1-2 years of use but decreases with continued use. Despite this, there is a significant body of evidence indicating that aspirin can reduce the risk of cancer, particularly colorectal cancer, and also lower the risk of metastases. Additionally, stopping aspirin use can lead to a temporary increase in the risk of myocardial infarction. Currently, there is no consensus on whether aspirin or other antiplatelets should be recommended for primary prevention in otherwise healthy patients due to insufficient evidence.

    • This question is part of the following fields:

      • Cardiovascular Health
      56.3
      Seconds
  • Question 5 - 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: 5

      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
      74.3
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  • Question 6 - You are reviewing current guidance in relation to the use of non-HDL cholesterol...

    Correct

    • You are reviewing current guidance in relation to the use of non-HDL cholesterol measurement with regards lipid modification therapy for cardiovascular disease prevention.
      Which of the following lipoproteins contribute to 'non-HDL cholesterol'?

      You are reviewing current guidance in relation to the use of non-HDL cholesterol measurement with regards lipid modification therapy for cardiovascular disease prevention.

      Which of the following lipoproteins contribute to 'non-HDL cholesterol'?

      Your Answer: LDL, IDL and VLDL cholesterol

      Explanation:

      The Importance of Non-HDL Cholesterol in Statin Treatment

      NICE guidelines recommend that high-intensity statin treatment for both primary and secondary prevention of cardiovascular disease should aim for a greater than 40% reduction in non-HDL cholesterol. Non-HDL cholesterol includes LDL, IDL, and VLDL cholesterol. In the past, LDL reduction has been used as a marker of statin effect. However, non-HDL reduction is more useful as it takes into account the atherogenic properties of IDL and VLDL cholesterol, which may be raised even in the presence of normal LDL levels.

      Using non-HDL cholesterol also has other benefits. Hypertriglyceridaemia can interfere with lab-based LDL calculations, but it doesn’t impact non-HDL calculation, which is measured by a different method. Additionally, a fasting sample is not required to measure non-HDL cholesterol, making sampling and monitoring easier. Overall, non-HDL cholesterol is an important marker to consider in statin treatment for cardiovascular disease prevention.

    • This question is part of the following fields:

      • Cardiovascular Health
      45.2
      Seconds
  • Question 7 - What factors in a patient's medical record could potentially elevate natriuretic peptide levels...

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Cardiovascular Health
      37.8
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  • Question 8 - Samantha is a 55-year-old female with hypertension which has been relatively well controlled...

    Correct

    • Samantha is a 55-year-old female with hypertension which has been relatively well controlled with lisinopril for 5 years. Her past medical history includes hypercholesterolaemia and osteoporosis.

      During a routine check with the nurse, Samantha's blood pressure was 160/100 mmHg. As a result, she has scheduled an appointment to see you and has brought her home blood pressure readings recorded over 7 days.

      The readings show an average blood pressure of 152/96 mmHg. What would be the most appropriate next step in managing Samantha's condition?

      Your Answer: Continue ramipril and commence amlodipine

      Explanation:

      If a patient with hypertension is already taking an ACE inhibitor and has a history of gout, it would be more appropriate to prescribe a calcium channel blocker as the next step instead of a thiazide. This is because thiazide-type diuretics should be used with caution in individuals with gout as it may worsen the condition. Therefore, a calcium channel blocker should be considered as a second-line Antihypertensive medication.

      It would be incorrect to make no changes to the patient’s medication, especially if their blood pressure readings are consistently high. In this case, a second-line Antihypertensive medication is necessary.

      Stopping the patient’s current medication, ramipril, is also not recommended as it is providing some Antihypertensive effects. Instead, a second medication should be added to further manage the patient’s 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.

    • This question is part of the following fields:

      • Cardiovascular Health
      75.8
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  • Question 9 - An 80-year-old man comes in for a medication review. He has a history...

    Correct

    • An 80-year-old man comes in for a medication review. He has a history of ischaemic heart disease, cerebrovascular disease, and heart failure. Which of the following medications should be prescribed using brand names only?

      Your Answer: Modified-release verapamil

      Explanation:

      To ensure effective symptom control, it is important to prescribe modified release calcium channel blockers by their specific brand names, as their release characteristics can vary. Therefore, it is necessary to maintain consistency in the brand prescribed.

      Prescribing Guidance for Healthcare Professionals

      Prescribing medication is a crucial aspect of healthcare practice, and it is essential to follow good practice guidelines to ensure patient safety and effective treatment. The British National Formulary (BNF) provides guidance on prescribing medication, including the recommendation to prescribe drugs by their generic name, except for specific preparations where the clinical effect may differ. It is also important to avoid unnecessary decimal points when writing numbers, such as prescribing 250 ml instead of 0.25 l. Additionally, it is a legal requirement to specify the age of children under 12 on their prescription.

      However, there are certain drugs that should be prescribed by their brand name, including modified release calcium channel blockers, antiepileptics, ciclosporin and tacrolimus, mesalazine, lithium, aminophylline and theophylline, methylphenidate, CFC-free formulations of beclomethasone, and dry powder inhaler devices. By following these prescribing guidelines, healthcare professionals can ensure safe and effective medication management for their patients.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 10 - A 65-year-old man presents to his General Practitioner for his annual asthma review....

    Correct

    • A 65-year-old man presents to his General Practitioner for his annual asthma review. He has no daytime symptoms and occasionally uses his ventolin inhaler at night when suffering from a viral infection. His only other medical history is of urinary incontinence, for which he has been fully investigated, and three episodes of gout in the last five years.
      On examination, his respiratory rate is 16 breaths per minute, his heart rate 64 bpm and his blood pressure is 168/82 mmHg. Subsequent home blood pressure readings confirm isolated systolic hypertension.
      Which of the following is the single most suitable medication for this patient?

      Your Answer: Amlodipine

      Explanation:

      Management of Isolated Systolic Hypertension: Drug Options and Considerations

      Isolated systolic hypertension, characterized by elevated systolic blood pressure and normal diastolic blood pressure, is managed similarly to systolic plus diastolic hypertension. Amlodipine, a dihydropyridine calcium-channel blocker, is the preferred first-line drug for treating isolated systolic hypertension in patients over 55 years old.

      Before starting any medication, a new diagnosis of hypertension should be confirmed through ambulatory blood pressure monitoring or home blood pressure monitoring. Additionally, an assessment for evidence of end-organ damage and 10-year cardiovascular risk should be conducted, along with a discussion about modifiable risk factors such as diet, exercise, sodium intake, alcohol consumption, caffeine, and smoking.

      Indapamide, a thiazide diuretic, is typically used as a second or third step in the treatment protocol. However, it may exacerbate gout and worsen urinary problems.

      Beta-blockers, such as atenolol, were previously recommended as second-line treatment for hypertension. However, they can cause hyperglycemia and are now at step 4 of the management plan. Beta-blockers are also contraindicated in asthma, making them unsuitable for some patients.

      Doxazosin, which is at step 4 of the hypertension management plan, may cause urinary incontinence and is not appropriate for all patients.

      Valsartan, an angiotensin 2 receptor blocker, is a first-line option for patients under 55 years old, along with an angiotensin-converting enzyme (ACE) inhibitor. It may be added at step 2 if necessary for patients over 55 years old.

    • This question is part of the following fields:

      • Cardiovascular Health
      45.9
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  • Question 11 - A 58-year-old man has persistent atrial fibrillation.
    Which of the following is the single...

    Correct

    • A 58-year-old man has persistent atrial fibrillation.
      Which of the following is the single risk factor that places him most at risk of stroke?

      Your Answer: Previous transient ischaemic attack

      Explanation:

      Understanding CHA2DS2-VASc Scoring for Stroke Risk in Atrial Fibrillation Patients

      The CHA2DS2-VASc scoring system is a useful tool for predicting the risk of stroke in patients with atrial fibrillation. A score of 0 indicates a low risk, while a score of 1 suggests a moderate risk, and a score of 2 or higher indicates a high risk. One of the risk factors that carries a score of 2 is a previous transient ischaemic attack, while age 75 years or older is another. Other risk factors, such as age 65-74 and female sex at any age, carry a score of 1 each. If a patient has no risk factors, their score would be zero, and not anticoagulating them would be an option. However, it is important to consider bleeding risk, calculated using the ORBIT criteria, before starting anticoagulation in all cases.

    • This question is part of the following fields:

      • Cardiovascular Health
      18.5
      Seconds
  • Question 12 - In a patient with atrial fibrillation, which option warrants hospital admission or referral...

    Incorrect

    • In a patient with atrial fibrillation, which option warrants hospital admission or referral for urgent assessment and intervention the most?

      Your Answer: Age less than 50 years

      Correct Answer: Apex beat 155 bpm

      Explanation:

      Urgent Admission Criteria for Patients with Atrial Fibrillation

      The National Institute for Health and Care Excellence has provided guidelines for urgent admission of patients with atrial fibrillation. These guidelines recommend urgent admission for patients who exhibit a rapid pulse greater than 150 bpm and/or low blood pressure with systolic blood pressure less than 90 mmHg. Additionally, urgent admission is recommended for patients who experience loss of consciousness, severe dizziness, ongoing chest pain, or increasing breathlessness. Patients who have experienced a complication of atrial fibrillation, such as stroke, transient ischaemic attack, or acute heart failure, should also be urgently admitted. While other symptoms may warrant a referral, these criteria indicate the need for immediate medical attention.

    • This question is part of the following fields:

      • Cardiovascular Health
      31.3
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  • Question 13 - A 67-year-old man presents for a medication review after being discharged from the...

    Correct

    • A 67-year-old man presents for a medication review after being discharged from the hospital three months ago following a cholecystectomy. He was started on several new medications due to hypertension and atrial fibrillation. Despite feeling well, he has noticed ankle swelling and suspects it may be a side effect of one of the new medications.

      During the examination, his blood pressure is 124/82 mmHg, and his heart rate is 68/min irregularly irregular.

      Which medication is most likely responsible for the observed side effect?

      Your Answer: Felodipine

      Explanation:

      Felodipine is more likely to cause ankle swelling than verapamil compared to dihydropyridines like amlodipine. Calcium channel blockers are commonly used as a first-line treatment for hypertension in patients over 55 years old, but a common side effect is peripheral edema. Dihydropyridines, such as amlodipine, work by selectively targeting vascular smooth muscle receptors, causing vasodilation and increased capillary pressure, which can lead to ankle edema. On the other hand, non-dihydropyridines like verapamil are more selective for myocardial calcium receptors, resulting in reduced cardiac contraction and heart rate.

      Calcium channel blockers are a class of drugs commonly used to treat cardiovascular disease. These drugs target voltage-gated calcium channels found in myocardial cells, cells of the conduction system, and vascular smooth muscle. The different types of calcium channel blockers have varying effects on these areas, making it important to differentiate their uses and actions.

      Verapamil is used to treat angina, hypertension, and arrhythmias. It is highly negatively inotropic and should not be given with beta-blockers as it may cause heart block. Side effects include heart failure, constipation, hypotension, bradycardia, and flushing.

      Diltiazem is used to treat angina and hypertension. It is less negatively inotropic than verapamil, but caution should still be exercised when patients have heart failure or are taking beta-blockers. Side effects include hypotension, bradycardia, heart failure, and ankle swelling.

      Nifedipine, amlodipine, and felodipine are dihydropyridines used to treat hypertension, angina, and Raynaud’s. They affect peripheral vascular smooth muscle more than the myocardium, which means they do not worsen heart failure but may cause ankle swelling. Shorter acting dihydropyridines like nifedipine may cause peripheral vasodilation, resulting in reflex tachycardia. Side effects include flushing, headache, and ankle swelling.

      According to current NICE guidelines, the management of hypertension involves a flow chart that takes into account various factors such as age, ethnicity, and comorbidities. Calcium channel blockers may be used as part of the treatment plan depending on the individual patient’s needs.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 14 - You are evaluating a 65-year-old new patient to the clinic who has a...

    Incorrect

    • You are evaluating a 65-year-old new patient to the clinic who has a history of established cardiovascular disease (CVD), having suffered a myocardial infarction 12 months ago.

      Previously, he declined taking a statin due to concerns about potential side effects, but he has since researched the topic and is now open to the idea.

      He currently takes aspirin 75 mg daily, ramipril 5 mg once daily, and bisoprolol 2.5 mg once daily. He has no other significant medical history. Recent blood tests indicate normal renal, liver, and thyroid function.

      What is the most appropriate course of action for management at this stage?

      Your Answer: Use QRISK2 risk assessment tool to assess his cardiovascular risk

      Correct Answer: Offer ezetimibe 10 mg daily

      Explanation:

      Statin Therapy for Those with Pre-existing CVD

      All individuals with a history of established cardiovascular disease (CVD) should be offered statin therapy, according to NICE guidelines. While diet and lifestyle modifications are important, they should not delay or withhold statin therapy.

      For those with pre-existing CVD (excluding chronic kidney disease), atorvastatin 80 mg daily is recommended. However, for individuals with chronic kidney disease and an eGFR of less than 60 mL/min/1.73m2, a lower dose of atorvastatin 20 mg daily is advised. Lower doses may also be considered for those at higher risk of side effects or due to individual preference.

      It is not necessary to use the QRISK2 risk assessment tool for those with pre-existing CVD, as they are automatically considered at high risk of CVD and should be treated accordingly. Overall, statin therapy is an important component of managing CVD and should be considered for all individuals with a history of the disease.

    • This question is part of the following fields:

      • Cardiovascular Health
      87
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  • Question 15 - A 56-year-old man with a history of smoking, obesity, prediabetes, and high cholesterol...

    Incorrect

    • A 56-year-old man with a history of smoking, obesity, prediabetes, and high cholesterol visits his GP complaining of chest pains that occur during physical activity or climbing stairs to his office. The pain is crushing in nature and subsides with rest. The patient is currently taking atorvastatin 20 mg and aspirin 75 mg daily. He has no chest pains at the time of the visit and is otherwise feeling well. Physical examination reveals no abnormalities. The GP prescribes a GTN spray for the chest pains and refers the patient to the rapid access chest pain clinic.

      What other medication should be considered in addition to the GTN?

      Your Answer: Clopidogrel

      Correct Answer: Bisoprolol

      Explanation:

      For the patient with stable angina, it is recommended to use a beta-blocker or a calcium channel blocker as the first-line treatment to prevent angina attacks. In this case, a cardioselective beta-blocker like bisoprolol or atenolol, or a rate-limiting calcium channel blocker such as verapamil or diltiazem should be considered while waiting for chest clinic assessment.

      As the patient is already taking aspirin 75 mg daily, there is no need to prescribe dual antiplatelet therapy. Aspirin is the preferred antiplatelet for stable angina.

      Since the patient is already taking atorvastatin, a fibrate like ezetimibe may not be necessary for lipid modification. However, if cholesterol levels or cardiovascular risk remain high, increasing the atorvastatin dose or encouraging positive lifestyle interventions like weight loss and smoking cessation can be helpful.

      It is important to note that nifedipine, a dihydropyridine calcium channel blocker, is not recommended as the first-line treatment for angina management as it has limited negative inotropic effects. It can be used in combination with a beta-blocker if monotherapy is insufficient for symptom control.

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

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

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 16 - A 72-year-old man presents to the General Practitioner with complaints of leg pain...

    Incorrect

    • A 72-year-old man presents to the General Practitioner with complaints of leg pain while walking. Upon examination, his feet appear cool and dusky, with the right foot being more affected than the left. An ankle brachial pressure index is measured at 0.8 on the right and 0.9 on the left. Both femoral pulses are present, but posterior tibial and dorsalis pedis pulses are absent in both legs. His blood pressure is 140/85 mmHg.
      Which of the following medications is LEAST likely to provide relief for his symptoms?

      Your Answer: Simvastatin

      Correct Answer: Amlodipine

      Explanation:

      Treatment options for Peripheral Arterial Disease (PAD)

      Peripheral Arterial Disease (PAD) is a condition that causes intermittent claudication. Antiplatelet therapy is recommended for those with symptomatic disease to reduce major cardiovascular events. Clopidogrel is suggested as the drug of first choice by the National Institute for Health and Care Excellence (NICE). Angiotensin converting enzyme inhibitors have been shown to reduce cardiovascular morbidity and mortality in patients with PAD. However, they should be carefully monitored as more than 25% of patients have co-existent renal artery stenosis. Statins are also recommended as they reduce the risk of mortality, cardiovascular events and stroke in patients with PAD. Naftidrofuryl oxalate is an option for the treatment of intermittent claudication in people with PAD for whom vasodilator therapy is considered appropriate. Amlodipine, a calcium channel blocker, is not indicated for this case.

    • This question is part of the following fields:

      • Cardiovascular Health
      49.6
      Seconds
  • Question 17 - 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: Due to his risk factors he will be offered screening at age 60

      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.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 18 - A 57-year-old caucasian woman is diagnosed with stage 2 hypertension. Baseline investigations do...

    Incorrect

    • A 57-year-old caucasian woman is diagnosed with stage 2 hypertension. Baseline investigations do not reveal evidence of end-organ damage. She has a history of atrial fibrillation and takes apixaban. Her ECG is normal. Her QRISK3 score is calculated as 12.4%. She has no known drug allergies. Lifestyle advice is given and appropriate follow-up is scheduled. What is the most effective supplementary treatment choice?

      Your Answer:

      Correct Answer: Atorvastatin and amlodipine

      Explanation:

      According to NICE guidelines, patients who are aged 55 years or over and do not have type 2 diabetes or are of black African or African-Caribbean family origin and do not have type 2 diabetes (of any age) should be prescribed calcium-channel blockers as the first-line treatment for hypertension. In addition, this patient requires a statin for primary cardiovascular disease prevention.

      Amlodipine alone is not sufficient as she requires both an antihypertensive agent and lipid-lowering therapy.

      Atorvastatin and indapamide (a thiazide-like diuretic) is not the best option as indapamide is only recommended as a second-line antihypertensive agent if a calcium-channel blocker is contraindicated, not suitable or not tolerated.

      Atorvastatin and ramipril is also not the best option as ACE inhibitors (or angiotensin-II receptor antagonists) are first-line for patients under the age of 55 and not of black African or African-Caribbean family origin, or those with type 2 diabetes (irrespective of age or family origin).

      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 19 - A 35-year-old man is referred by the practice nurse following a routine health...

    Incorrect

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

      Your Answer:

      Correct Answer: Statin

      Explanation:

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

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 20 - A patient with a history of heart failure experiences mild physical activity limitations....

    Incorrect

    • A patient with a history of heart failure experiences mild physical activity limitations. While at rest, she is comfortable, but everyday tasks like walking to nearby stores cause fatigue, palpitations, or dyspnea. Which New York Heart Association class accurately characterizes the extent of her condition?

      Your Answer:

      Correct Answer: NYHA Class II

      Explanation:

      NYHA Classification for Chronic Heart Failure

      Chronic heart failure is a condition that affects the heart’s ability to pump blood effectively. The New York Heart Association (NYHA) classification is a widely used system to categorize the severity of heart failure. The NYHA classification has four classes, each with a different level of symptoms and limitations.

      NYHA Class I refers to patients who have no symptoms and no limitations in their physical activity. They can perform ordinary physical exercise without experiencing fatigue, dyspnea, or palpitations.

      NYHA Class II patients have mild symptoms and slight limitations in their physical activity. They are comfortable at rest, but ordinary activity can cause fatigue, palpitations, or dyspnea.

      NYHA Class III patients have moderate symptoms and marked limitations in their physical activity. They are comfortable at rest, but less than ordinary activity can result in symptoms.

      NYHA Class IV patients have severe symptoms and are unable to carry out any physical activity without discomfort. Symptoms of heart failure are present even at rest, and any physical activity increases discomfort.

      In summary, the NYHA classification is a useful tool for healthcare professionals to assess the severity of chronic heart failure and determine appropriate treatment plans.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 21 - A 45-year-old male with type 2 diabetes is struggling to manage his hypertension....

    Incorrect

    • A 45-year-old male with type 2 diabetes is struggling to manage his hypertension. Despite being on atenolol, amlodipine, and ramipril, his blood pressure consistently reads above 170/100 mmHg. During examination, he was found to have grade II hypertensive retinopathy. His test results show sodium levels at 144 mmol/L (137-144), potassium at 3.1 mmol/L (3.5-4.9), urea at 5.5 mmol/L (2.5-7.5), creatinine at 100 mol/L (60-110), glucose at 7.9 mmol/L (3.0-6.0), and HbA1c at 53 mmol/mol (20-46) or 7% (3.8-6.4). Additionally, his ECG revealed left ventricular hypertrophy. What potential diagnosis should be considered as a cause of his resistant hypertension?

      Your Answer:

      Correct Answer: Renal artery stenosis

      Explanation:

      Diagnosis of Primary Hyperaldosteronism

      This patient is experiencing resistant hypertension and has a low potassium concentration despite being on an angiotensin-converting enzyme inhibitor (ACEi), which should have increased their potassium levels. These symptoms are highly suggestive of primary hyperaldosteronism, which can be caused by either an adrenal adenoma (Conn syndrome) or bilateral adrenal hyperplasia.

      To diagnose primary hyperaldosteronism, doctors typically look for an elevated aldosterone:renin ratio, which is usually above 1000. This condition can be challenging to diagnose, but it is essential to do so as it can lead to severe complications if left untreated. By identifying the underlying cause of the patient’s symptoms, doctors can develop an effective treatment plan to manage their hypertension and potassium levels.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 22 - 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 23 - A 68-year-old-man visits his General Practitioner complaining of syncope without any prodromal features....

    Incorrect

    • A 68-year-old-man visits his General Practitioner complaining of syncope without any prodromal features. He has noticed increased dyspnea on exertion in the past few weeks. He denies any chest pain and has no known history of cardiac issues. Upon examination, an electrocardiogram (ECG) is performed which reveals complete heart block.
      Which of the following physical findings is most indicative of the diagnosis?
      Select ONE answer only.

      Your Answer:

      Correct Answer: Irregular cannon ‘A’ waves on jugular venous pressure

      Explanation:

      Understanding the Clinical Signs of Complete Heart Block

      Complete heart block is a condition where there is a complete failure of conduction through the atrioventricular node, resulting in bradycardia and potential symptoms such as dizziness, fatigue, dyspnea, and chest pain. Here are some clinical signs to look out for when assessing a patient with complete heart block:

      Irregular Cannon ‘A’ Waves on Jugular Venous Pressure: Cannon waves are large A waves that occur irregularly when the right atrium contracts against a closed tricuspid valve. In complete heart block, these waves occur randomly due to atrioventricular dissociation.

      Low-Volume Pulse: Complete heart block doesn’t necessarily create a low-volume pulse. This is typically found in other conditions such as shock, left ventricular dysfunction, or mitral stenosis.

      Irregularly Irregular Pulse: The ‘escape rhythms’ in third-degree heart block usually produce a slow, regular pulse that doesn’t vary with exercise. Unless found in combination with another condition such as atrial fibrillation, the pulse should be regular.

      Collapsing Pulse: A collapsing pulse is typically associated with aortic regurgitation and would not be expected with complete heart block alone.

      Loud Second Heart Sound: In complete heart block, the intensity of the first and second heart sound varies due to the loss of atrioventricular synchrony. A consistently loud second heart sound may be found in conditions such as pulmonary hypertension.

      By understanding these clinical signs, healthcare professionals can better diagnose and manage patients with complete heart block.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 24 - A 45-year-old man is brought to the Emergency Department following a fall. He...

    Incorrect

    • A 45-year-old man is brought to the Emergency Department following a fall. He recalled rushing for the train before feeling dizzy. His father recently died suddenly because of a heart problem. On examination, he has a ‘jerky’ pulse, a thrusting apex beat with double impulse and a late ejection systolic murmur which diminishes on squatting.
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Hypertrophic cardiomyopathy

      Explanation:

      Hypertrophic cardiomyopathy is a genetic heart condition that is the leading cause of sudden cardiac death in young people. It is characterized by an enlarged left ventricle, which can cause obstruction of blood flow. A jerky pulse and an intensifying systolic murmur during activities that decrease blood volume in the left ventricle are common examination findings. Aortic stenosis, Brugada syndrome, mitral regurgitation, and mitral valve prolapse are other heart conditions that have different symptoms and examination findings.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 25 - 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 26 - A 58-year-old man with a history of hypertension experiences sudden onset of severe...

    Incorrect

    • A 58-year-old man with a history of hypertension experiences sudden onset of severe chest pain, radiating to the back and left shoulder. On examination, he is hemiplegic, with pallor and sweating. His heart rate is 120 bpm and his blood pressure is 174/89 mmHg, but 153/72 mmHg when measured on the opposite arm.
      What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Dissection of the thoracic aorta

      Explanation:

      Differential diagnosis of hemiplegia in a patient with chest pain

      Aortic dissection, myocardial infarction, intracranial haemorrhage, ruptured thoracic aneurysm, and ruptured ventricular aneurysm are among the possible causes of chest pain and hemiplegia in a patient with a history of hypertension. Aortic dissection is the most likely diagnosis, given the abrupt onset and maximal severity of chest pain at onset, as well as the potential for carotid involvement and limb blood pressure differences. Myocardial infarction may also cause chest pain but is less likely to present with hemiplegia. Intracranial haemorrhage may cause hemiplegia but is more likely to present with a headache. Ruptured thoracic aneurysm may cause acute chest, back, or neck pain, but is unlikely to cause hemiplegia. Ruptured ventricular aneurysm is a complication of myocardial infarction but typically doesn’t rupture. A careful differential diagnosis is essential for appropriate management and prognosis.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 27 - You are asked to do a new baby check on a 4-day-old boy...

    Incorrect

    • You are asked to do a new baby check on a 4-day-old boy born at home after an uneventful pregnancy. The labour was normal and the baby has been fine until today, when he was noted to be slightly blue around the lips on feeding, recovering quickly. On examination there is a systolic murmur and you are unable to feel pulses in the legs.
      Select the single most likely diagnosis.

      Your Answer:

      Correct Answer: Coarctation of the aorta

      Explanation:

      Common Congenital Heart Defects in Newborns

      Congenital heart defects are abnormalities in the structure of the heart that are present at birth. Here are some common congenital heart defects in newborns:

      Coarctation of the aorta: This defect is a narrowing of the aorta, usually just distal to the origin of the left subclavian artery, close to the ductus arteriosus. It usually presents between day 2 and day 6 with symptoms of heart failure as the ductus arteriosus closes. The patient may have weak femoral pulses and a systolic murmur in the left infraclavicular area.

      Fallot’s tetralogy: This defect consists of a large ventricular septal defect, overriding aorta, right ventricular outflow obstruction, and right ventricular hypertrophy. It leads to a right to left shunt and low oxygen saturation, which can cause cyanosis. Most cases are diagnosed antenatally or on investigation of a heart murmur.

      Ductus arteriosus: The ductus arteriosus connects the pulmonary artery to the proximal descending aorta. It is a normal structure in fetal life but should close after birth. Failure of the ductus arteriosus to close can lead to overloading of the lungs because a left to right shunt occurs. Heart failure may be a consequence. A continuous (“machinery”) murmur is best heard at the left infraclavicular area or upper left sternal border.

      Transient tachypnoea of the newborn: This condition is seen shortly after delivery and consists of a period of rapid breathing. It is likely due to retained lung fluid and usually resolves over 24-48 hours. However, it is important to observe for signs of clinical deterioration.

      Ventricular septal defects: These defects vary in size and haemodynamic consequences. The presence of a defect may not be obvious at birth. Classically there is a harsh systolic murmur that is best heard at the left sternal edge. With large defects, pulmonary hypertension may develop resulting in a right to left shunt (Eisenmenger’s syndrome). Patients with the latter may have no murmur.

      In conclusion, early detection and management of congenital heart defects in newborns are crucial for better outcomes.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 28 - A 65-year old man has had syncopal attacks and exertional chest pain which...

    Incorrect

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

      Your Answer:

      Correct Answer: Left ventricular failure

      Explanation:

      Understanding Prognostic Factors in Aortic Stenosis

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

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

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

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

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 29 - A 45-year-old woman is newly diagnosed with ankylosing spondylitis. An echocardiogram shows a...

    Incorrect

    • A 45-year-old woman is newly diagnosed with ankylosing spondylitis. An echocardiogram shows a valvular anomaly.
      What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Aortic regurgitation

      Explanation:

      Cardiovascular Complications in Ankylosing Spondylitis

      Ankylosing spondylitis is a chronic inflammatory disease that primarily affects the spine and sacroiliac joints. However, it can also lead to cardiovascular complications. The most common complication is aortic regurgitation, which occurs due to inflammation of the ascending aorta. On the other hand, mitral regurgitation is not typically associated with ankylosing spondylitis and is usually caused by congenital conditions or cardiomyopathies. Aortic stenosis is also not commonly associated with ankylosing spondylitis, as it is usually caused by age-related calcification or congenital bicuspid valve. Similarly, mitral stenosis is more commonly associated with rheumatic heart disease than ankylosing spondylitis. Tricuspid stenosis is a rare cardiac defect that is usually associated with rheumatic fever. Therefore, it is important for individuals with ankylosing spondylitis to be aware of the potential cardiovascular complications and to seek medical attention if any symptoms arise.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 30 - 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.

    • This question is part of the following fields:

      • Cardiovascular Health
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Cardiovascular Health (10/17) 59%
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