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  • Question 1 - Your next appointment is with a 48-year-old man. He has come for the...

    Incorrect

    • Your next appointment is with a 48-year-old man. He has come for the results of his ambulatory blood pressure monitoring (ABPM). This was arranged as a clinic reading one month ago was noted to be 150/94 mmHg. The results of the ABPM show an average reading of 130/80 mmHg. What is the most suitable plan of action?

      Your Answer: Offer repeat ABPM in 12 months time

      Correct Answer: Offer to measure the patient's blood pressure at least every 5 years

      Explanation:

      If the ABPM indicates an average blood pressure below the threshold, NICE suggests conducting blood pressure measurements on the patient every 5 years.

      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 2 - A 55-year-old woman presents to you for a follow-up blood pressure check. She...

    Incorrect

    • A 55-year-old woman presents to you for a follow-up blood pressure check. She has been evaluated by two other physicians in the past three months, with readings of 140/90 mmHg and 148/86 mmHg. Her current blood pressure is 142/84 mmHg. She has no familial history of hypertension, her BMI is 23, and she is a non-smoker. Based on the most recent NICE recommendations, what is the recommended course of action?

      Your Answer: Reassure only

      Correct Answer: Check ECG and blood tests and see her again in a month with the results

      Explanation:

      Understanding Hypertension Diagnosis and Management

      Hypertension is a common condition that requires careful diagnosis and management. According to the 2019 NICE guidance on Hypertension (NG136), ambulatory or home blood pressure should be checked if a patient has a blood pressure equal to or greater than 140/90 mmHg. If the systolic reading is above 140 mmHg, it is considered a sign of hypertension.

      The guidelines also state that lifestyle advice should be given to all patients, and drug treatment should be considered if there are signs of end organ damage or if the patient’s CVD risk is greater than 10% in 10 years. For patients under 40 years old, referral to a specialist should be considered.

      It is important to note that NICE guidance is not the only source of information on hypertension diagnosis and management. While it is important to have an awareness of the latest guidance, it is also important to have a balanced view and consider other guidelines and consensus opinions.

      In summary, understanding the diagnosis and management of hypertension is crucial for general practitioners. The 2019 NICE guidance on Hypertension provides important information on thresholds for diagnosis and management, but it is important to consider other sources of information as well.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 3 - A GP receives notification from the Abdominal Aortic Aneurysm Screening program that one...

    Incorrect

    • A GP receives notification from the Abdominal Aortic Aneurysm Screening program that one of his elderly patients has been found to have an aneurysm measuring 6.5cm in diameter. What should be the next course of action?

      Your Answer: Follow-up with screening programme Nurse Specialist

      Correct Answer: Refer to Vascular Outpatients

      Explanation:

      If the aortic diameter is within normal range, the patient is discharged from the screening programme. However, if small or medium AAAs are detected, the patient will be scheduled for regular follow-up appointments with a Nurse Specialist from the screening programme and surveillance scans. In the event of a large AAA (measuring over 5.5 cm in diameter), the patient must be referred to Vascular Outpatients and seen within 2 weeks. While the screening programme will initiate the referral process, the GP will also be urgently contacted to provide additional information such as the patient’s medical history. If surgery is deemed necessary, it should be performed within 8 weeks of the referral.

      Understanding Abdominal Aortic Aneurysms

      Abdominal aortic aneurysms occur when the elastic proteins in the extracellular matrix fail, causing the arterial wall to dilate. This is typically caused by degenerative disease and can be identified by a diameter of 3 cm or greater. The development of aneurysms is complex and involves the loss of the intima and elastic fibers from the media, which is associated with increased proteolytic activity and lymphocytic infiltration.

      Smoking and hypertension are major risk factors for the development of aneurysms, while rare causes include syphilis and connective tissue diseases such as Ehlers Danlos type 1 and Marfan’s syndrome. It is important to understand the underlying causes and risk factors for abdominal aortic aneurysms in order to prevent and treat this potentially life-threatening condition.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 4 - You are reviewing a 75-year-old woman.
    You saw her several weeks ago with a...

    Incorrect

    • You are reviewing a 75-year-old woman.
      You saw her several weeks ago with a clinical diagnosis of heart failure and a high brain natriuretic peptide level. You referred her for echocardiography and cardiology assessment. Following the referral she now has a diagnosis of 'Heart failure with reduced ejection fraction'.
      Providing there are no contraindications, which of the following combinations of medication should be used as first line treatment in this patient?

      Your Answer:

      Correct Answer: ACE inhibitor and beta blocker

      Explanation:

      Treatment for Heart Failure with Left Ventricular Systolic Dysfunction

      Angiotensin-converting enzyme (ACE) inhibitors and beta-blockers are recommended for patients with heart failure due to left ventricular systolic dysfunction, regardless of their NYHA functional class. The 2003 NICE guidance suggests starting with ACE inhibitors and then adding beta-blockers, but the 2010 update recommends using clinical judgement to determine which drug to start first. For example, a beta-blocker may be more appropriate for a patient with angina or tachycardia. However, combination treatment with an ACE inhibitor and beta-blocker is the preferred first-line treatment for patients with heart failure due to left ventricular dysfunction. It is important to start drug treatment in a stepwise manner and to ensure the patient’s condition is stable before initiating therapy.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 5 - You have been asked to review the blood pressure of a 67-year-old woman....

    Incorrect

    • You have been asked to review the blood pressure of a 67-year-old woman. She was recently seen by the practice nurse for her annual health review and her blood pressure measured at the time was 148/90 mmHg. There is no history of headache, visual changes or symptoms suggestive of heart failure. Her past medical history includes hypertension, osteoporosis and type 2 diabetes. The medications she is currently on include amlodipine, alendronate, metformin, and lisinopril.

      On examination, her blood pressure is 152/88 mmHg. Cardiovascular exam is unremarkable. Fundoscopy shows a normal fundi. The results of the blood test from two days ago are as follow:

      Na+ 140 mmol/L (135 - 145)
      K+ 4.2 mmol/L (3.5 - 5.0)
      Bicarbonate 26 mmol/L (22 - 29)
      Urea 5.5 mmol/L (2.0 - 7.0)
      Creatinine 98 µmol/L (55 - 120)

      What is the most appropriate next step in managing her blood pressure?

      Your Answer:

      Correct Answer: Alpha-blocker

      Explanation:

      If a patient has poorly controlled hypertension despite taking an ACE inhibitor, calcium channel blocker, and a standard-dose thiazide diuretic, and their potassium level is above 4.5mmol/l, NICE recommends adding an alpha-blocker or seeking expert advice. In this case, as the patient is asthmatic, a beta-blocker is contraindicated, making an alpha-blocker the appropriate choice. However, if the patient’s potassium level was less than 4.5, a low-dose aldosterone antagonist could be considered as an off-license use. Referral for specialist assessment is only recommended if blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, which is not the case for this patient who is currently taking three antihypertensive agents.

      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 6 - A 65-year-old man undergoes an abdominal ultrasound as part of investigations for persistent...

    Incorrect

    • A 65-year-old man undergoes an abdominal ultrasound as part of investigations for persistent mildly abnormal liver function tests. The liver appears normal but he is found to have an abdominal aortic aneurysm (AAA).
      Select from the list the single correct statement regarding an unruptured abdominal aortic aneurysm.

      Your Answer:

      Correct Answer: Elective repair of an aneurysm has a significant mortality risk

      Explanation:

      Unruptured Abdominal Aortic Aneurysm: Symptoms, Risks, and Treatment Options

      Abdominal Aortic Aneurysm (AAA) is a condition that often goes unnoticed due to the lack of symptoms. It is usually discovered incidentally during abdominal examinations or scans. However, bimanual palpation of the supra-umbilical region can detect a significant number of aneurysms. While most patients do not experience any pain, severe lumbar pain may indicate an impending rupture. The risk of rupture increases with the size of the aneurysm, with an annual rupture rate of 0.5-1.5% for aneurysms between 4.0 and 5.5 cm, and 5-15% for those between 5.5 and 6.0 cm.

      The natural history of a small AAA is gradual expansion, with an annual rate of approximately 10% of the initial arterial diameter. The mortality rate from a ruptured AAA is high, at 80%. However, elective repair can significantly reduce the risk of rupture. The overall mortality rate for elective repair in the UK is 2.4%, with a lower mortality rate for endovascular aneurysm repair (EVAR) than open surgery.

      It is important for drivers to notify the DVLA of any AAA, as it may affect their ability to drive. Group 1 drivers should notify the DVLA of an aneurysm >6 cm, while >6.5 cm would disqualify them from driving. Group 2 drivers should notify the DVLA of an aneurysm of any size, and an aortic diameter >5.5 cm would disqualify them from driving.

      In conclusion, while most patients with unruptured AAA do not experience any symptoms, it is important to be aware of the risks and treatment options. Early detection and elective repair can significantly reduce the risk of rupture and improve outcomes.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 7 - A patient is at highest risk of developing venous thromboembolism due to which...

    Incorrect

    • A patient is at highest risk of developing venous thromboembolism due to which of the following options? Please select only one.

      Your Answer:

      Correct Answer: Hip fracture

      Explanation:

      Predisposing Factors for Pulmonary Embolism

      Pulmonary embolism is a serious medical condition that occurs when a blood clot travels to the lungs and blocks blood flow. Certain factors can increase the risk of developing pulmonary embolism.

      Strong predisposing factors, with an odds ratio greater than 10, include fractures (hip or leg), hip or knee replacement, major general surgery, major trauma, and spinal cord injury.

      Moderate predisposing factors, with an odds ratio between 2 and 9, include arthroscopic knee surgery, central venous lines, chemotherapy, chronic heart or respiratory failure, hormone replacement therapy, malignancy, oral contraceptive therapy, paralytic stroke, pregnancy/postpartum, previous venous thromboembolism, and thrombophilia.

      Weak predisposing factors, with an odds ratio of 2 or less, include bed rest for more than 3 days, immobility due to sitting (such as prolonged car or air travel), increasing age, laparoscopic surgery (such as cholecystectomy), obesity, pregnancy/antepartum, and varicose veins.

      It is important to be aware of these predisposing factors and take appropriate measures to prevent pulmonary embolism, especially in high-risk individuals.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 8 - A man of 65 comes to see you with a suspected fungal nail...

    Incorrect

    • A man of 65 comes to see you with a suspected fungal nail infection.

      You notice he has not had his blood pressure taken for many years. The lowest reading observed is 175/105 mmHg. Fundoscopy is normal and his pulse is of normal rate and rhythm. He is otherwise well.

      With reference to the latest NICE guidance on Hypertension (NG136), what is your next action?

      Your Answer:

      Correct Answer: Repeat his blood pressure in a month

      Explanation:

      Management of Hypertension in Primary Care

      Referring a patient to the hospital for hypertension without suspicion of accelerated hypertension is inappropriate. According to the updated NICE guidelines on Hypertension (NG136) in September 2019, immediate treatment should only be considered if the blood pressure is equal to or greater than 180/120 mmHg. In this case, it is recommended to bring the patient back for ambulatory monitoring or record their home blood pressure readings for at least four days. Repeating blood pressure with the nurse is no longer preferred, as ambulatory or home readings are considered better. The presence of a fungal nail infection is irrelevant, but it may be necessary to check the patient’s fasting blood sugar or HbA1c to rule out diabetes. When answering AKT questions, it is important to consider the bigger picture and remember that the questions test knowledge of national guidance and consensus opinion, not just the latest NICE guidance.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 9 - A 38-year-old man presents to clinic for a routine check-up. He is concerned...

    Incorrect

    • A 38-year-old man presents to clinic for a routine check-up. He is concerned about his risk for heart disease as his father had a heart attack at the age of 50. He reports a non-smoking history, a blood pressure of 128/82 mmHg, and a body mass index of 25 kg/m.

      His recent blood work reveals the following results:

      - Sodium: 142 mmol/L
      - Potassium: 3.8 mmol/L
      - Urea: 5.2 mmol/L
      - Creatinine: 78 mol/L
      - Total cholesterol: 6.8 mmol/L
      - HDL cholesterol: 1.3 mmol/L
      - LDL cholesterol: 4.5 mmol/L
      - Triglycerides: 1.2 mmol/L
      - Fasting glucose: 5.1 mmol/L

      Based on these results, his QRISK2 score is calculated to be 3.5%. What is the most appropriate plan of action for this patient?

      Your Answer:

      Correct Answer: Refer him to a specialist lipids clinic

      Explanation:

      The 2014 NICE lipid modification guidelines provide recommendations for familial hyperlipidaemia. Individuals with a total cholesterol concentration above 7.5 mmol/litre and a family history of premature coronary heart disease should be investigated for familial hypercholesterolaemia as described in NICE clinical guideline 71. Those with a total cholesterol concentration exceeding 9.0 mmol/litre or a nonHDL cholesterol concentration above 7.5 mmol/litre should receive specialist assessment, even if they do not have a first-degree family history of premature coronary heart disease.

      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 10 - Raj is a 50-year-old man who has been prescribed an Antihypertensive medication for...

    Incorrect

    • Raj is a 50-year-old man who has been prescribed an Antihypertensive medication for his high blood pressure. He visits you with a complaint of persistent bilateral ankle swelling for the past 3 weeks, which is causing him concern. Which of the following drugs is the probable cause of his new symptom?

      Your Answer:

      Correct Answer: Lacidipine

      Explanation:

      Ankle swelling is more commonly associated with dihydropyridine calcium channel blockers like amlodipine than with verapamil. Although ankle oedema is a known side effect of all calcium channel blockers, there are differences in the incidence of ankle oedema between the two classes. Therefore, lacidipine, which belongs to the dihydropyridine class, is more likely to cause ankle swelling than verapamil.

      Factors that increase the risk of developing ankle oedema while taking calcium channel blockers include being female, older age, having heart failure, standing upright, and being in warm environments.

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

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

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

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

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

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 11 - What is the only true statement about high blood pressure from the given...

    Incorrect

    • What is the only true statement about high blood pressure from the given list?

      Your Answer:

      Correct Answer: Treatment of hypertension reduces the risk of coronary heart disease by approximately 20%.

      Explanation:

      Understanding Hypertension: Prevalence, Types, and Treatment

      Hypertension, or high blood pressure, is a common condition that affects both men and women, with its prevalence increasing with age. Essential hypertension, which has no identifiable cause, is the most common type of hypertension, affecting 95% of hypertensive patients. However, indications for further evaluation include resistant hypertension and early, late, or rapid onset of high blood pressure.

      Reducing blood pressure by an average of 12/6 mm Hg can significantly reduce the risk of stroke and coronary heart disease. Salt restriction, alcohol reduction, smoking cessation, aerobic exercise, and weight loss can also help reduce blood pressure by 3-5 mmHg, comparable to some drug treatments.

      In severe cases, hypertension can lead to target organ damage, resulting in a hypertensive emergency. Malignant hypertension, which is diagnosed when papilloedema is present, can cause symptoms such as severe headache, visual disturbance, dyspnoea, chest pain, nausea, and neurological deficit.

      Understanding hypertension and its types is crucial in managing and treating this condition. By implementing lifestyle changes and seeking medical attention when necessary, individuals can reduce their risk of hypertension-related complications.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 12 - In this case where a 50-year-old man was diagnosed with hypertension and started...

    Incorrect

    • In this case where a 50-year-old man was diagnosed with hypertension and started on Ramipril 2.5mg, with subsequent blood tests showing a 20% reduction in eGFR but stable renal function and serum electrolytes, what would be the recommended course of action according to NICE guidelines?

      Your Answer:

      Correct Answer: Stop Ramipril and replace with calcium channel blocker

      Explanation:

      Managing Abnormal Results when Initiating or Increasing ACE-I Dose

      When initiating or increasing the dose of an ACE-I, it is important to monitor for any abnormal results. According to NICE, a slight increase in serum creatinine and potassium is expected. However, if the eGFR reduction is 25% or less (or serum creatinine increase of less than 30%), no modification to the treatment regime is needed, as long as no further reductions occur.

      If the eGFR decrease is 25% or more, it is important to consider other potential causes such as volume depletion, other nephrotoxic drugs, or vasodilators. If none of these are applicable, it may be necessary to stop the ACE-I or reduce the dose to a previously tolerated level. It is recommended to recheck levels in 5-7 days to ensure that the treatment is effective and safe for the patient. By closely monitoring and managing abnormal results, healthcare professionals can ensure that patients receive the best possible care when taking ACE-Is.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 13 - 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.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 14 - A 58-year-old African gentleman is seen by his GP at a first visit...

    Incorrect

    • A 58-year-old African gentleman is seen by his GP at a first visit registration medical.

      He is completely asymptomatic but his blood pressure measures 150/95 mmHg, then 148/90 mmHg and 155/98 mmHg on two further visits a few weeks apart. He is not taking any medication currently.

      What is the next best treatment option for this gentleman?

      Your Answer:

      Correct Answer: Organise a 24 hour ambulatory blood pressure monitoring

      Explanation:

      NICE Guidelines for Blood Pressure Monitoring

      The latest NICE guidelines recommend ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) before starting therapy, except for patients with severe hypertension (BP 180/120 mmHg). If the clinic blood pressure is 140/90 mmHg or higher, ABPM should be offered to confirm the diagnosis of hypertension. When using ABPM to confirm hypertension, it is important to take at least two measurements per hour during the person’s usual waking hours (e.g., between 08:00 and 22:00). To confirm a diagnosis of hypertension, the average value of at least 14 measurements taken during the person’s usual waking hours should be used. These guidelines aim to improve the accuracy of hypertension diagnosis and ensure appropriate treatment.

    • This question is part of the following fields:

      • Cardiovascular Health
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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:

      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 32-year-old man presents for an insurance medical. He has no significant medical...

    Incorrect

    • A 32-year-old man presents for an insurance medical. He has no significant medical history. During the examination, his BMI is 23 kg/m2, blood pressure is 110/70 mmHg, and auscultation of the heart reveals a mid-systolic click and a late systolic murmur (which are more pronounced when he stands up).
      What is the most likely diagnosis based on these findings?

      Your Answer:

      Correct Answer: Mitral valve prolapse

      Explanation:

      Understanding Mitral Valve Prolapse: Symptoms, Causes, and Associated Conditions

      Mitral valve prolapse is a condition where the leaflets of the mitral valve bulge in systole, affecting around 2-3% of the population. It can occur as an isolated entity or with heritable disorders of connective tissue. While most people are asymptomatic, some may experience symptoms such as anxiety, panic attacks, palpitations, syncope, or presyncope. The condition is also a risk factor for mitral regurgitation and carries a small risk of cerebral emboli and sudden death. Diagnosis is made through auscultation, with a mid-to-late systolic click and a late systolic murmur heard at the apex. Other heart conditions, such as atrial septal defect, aortic stenosis, mitral regurgitation, and mitral stenosis, have distinct murmurs that aid in diagnosis.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 17 - A 40-year-old man comes to the clinic for a hypertension review, as recommended...

    Incorrect

    • A 40-year-old man comes to the clinic for a hypertension review, as recommended by the practice nurse. Despite taking ramipril 10 mg, amlodipine 5 mg, and atenolol 50 mg, his blood pressure remains elevated at 150/90 mmHg. Upon checking his U&E, his sodium level is 140, potassium level is 3.4, and creatinine level is 110. What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Phaeochromocytoma

      Explanation:

      Diagnosis of Hyperaldosteronism

      Such difficult-to-control hypertension and hypokalaemia, despite maximal ACE inhibition, may indicate hyperaldosteronism. The preferred diagnostic investigation is a renin/aldosterone ratio off Antihypertensive medication, with a washout period of four to six weeks. MRI scanning can also help identify an aldosterone-producing tumour. In contrast, phaeochromocytoma typically presents with paroxysms of hypertension, accompanied by headache, anxiety, and sweating. Renal artery stenosis is expected to be associated with an abnormal creatinine in patients using ACE inhibitors. By identifying the underlying cause of hypertension, appropriate treatment can be initiated, leading to better outcomes for patients.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 18 - A 35-year-old woman of African origin comes in for a routine health check....

    Incorrect

    • A 35-year-old woman of African origin comes in for a routine health check. She is a non-smoker, drinks 14 units of alcohol per week, is physically fit, active, and enjoys regular moderate exercise and a balanced diet. Her BMI is 26.8 kg/m2. Her average BP measured by home monitoring for 7 days is 160/95.
      What is the most suitable initial course of action?

      Your Answer:

      Correct Answer: Start an ACE inhibitor

      Explanation:

      Treatment Recommendations for Hypertension

      Patients diagnosed with hypertension with a blood pressure reading of >150/95 mmHg (stage 2 hypertension) should be offered drug therapy. For patients younger than 55 years, an ACE inhibitor is recommended as the first-line treatment. However, patients over the age of 55 and black patients of any age should initially be treated with a calcium channel blocker or a thiazide diuretic. These recommendations aim to provide effective treatment options for patients with hypertension based on their age and race.

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      • Cardiovascular Health
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  • Question 19 - You are speaking with a 57-year-old man who is worried about his blood...

    Incorrect

    • 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:

      Correct 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.

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      • Cardiovascular Health
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  • Question 20 - A 50-year-old man with a medical history of type II diabetes mellitus presents...

    Incorrect

    • A 50-year-old man with a medical history of type II diabetes mellitus presents with hypertension on home blood pressure recordings (155/105 mmHg). His medical records indicate a recent hospitalization for pyelonephritis where he was diagnosed with renal artery stenosis. What is the most suitable medication to initiate for his hypertension management?

      Your Answer:

      Correct Answer: Amlodipine

      Explanation:

      In patients with renovascular disease, ACE inhibitors are contraindicated. Therefore, a calcium channel blocker like amlodipine would be the first-line treatment according to NICE guidelines. If hypertension persists despite CCB and thiazide-like diuretic treatment and serum potassium is over 4.5mmol/L, a cardioselective beta-blocker like carvedilol may be considered. If blood pressure is still not adequately controlled with a CCB, a thiazide-like diuretic such as indapamide would be the second-line treatment. Losartan, an angiotensin II receptor blocker, is also contraindicated in patients with renovascular disease for the same reason as ACE inhibitors.

      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.

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      • Cardiovascular Health
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  • Question 21 - 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 22 - A 6-year-old boy is found to have a systolic murmur.
    Select from the list...

    Incorrect

    • A 6-year-old boy is found to have a systolic murmur.
      Select from the list the single feature that would be most suggestive of this being an innocent murmur.

      Your Answer:

      Correct Answer: Heard during a febrile illness

      Explanation:

      Understanding Innocent Heart Murmurs in Children

      Innocent heart murmurs are common in children between the ages of 3 and 8 years. They occur when blood flows noisily through a normal heart, usually due to increased blood flow or faster blood movement. Innocent murmurs are typically systolic and vibratory in quality, with an intensity of 2/6 or 1/6. They can change with posture and vary from examination to examination. Harsh murmurs, pansystolic murmurs, late systolic murmurs, and continuous murmurs are usually indicative of pathology. Heart sounds in innocent murmurs are normal, with a split second heart sound in inspiration and a single second heart sound in expiration. It’s important to note that the absence of symptoms doesn’t exclude important pathology, and some murmurs due to congenital heart disease may not be easily audible at birth.

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      • Cardiovascular Health
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  • Question 23 - 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.

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      • Cardiovascular Health
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  • Question 24 - A 72-year-old man presents as he has suffered two episodes of syncope in...

    Incorrect

    • A 72-year-old man presents as he has suffered two episodes of syncope in the past three weeks and is feeling increasingly tired. On examination, his pulse is 40 bpm and his BP 100/60 mmHg. An ECG reveals he is in complete heart block.
      What other finding are you most likely to find?

      Your Answer:

      Correct Answer: Variable S1

      Explanation:

      Characteristics of Complete Heart Block

      Complete heart block is a condition where there is no coordination between the atrial and ventricular contractions. This results in a variable intensity of the first heart sound, which is the closure of the atrioventricular (AV) valves. The blood flow from the atria to the ventricles varies from beat to beat, leading to inconsistent intensity of the first heart sound. Additionally, cannon A waves may be observed in the neck, indicating atrial contraction against closed AV valves.

      Narrow pulse pressure is not a characteristic of complete heart block. It is more commonly associated with aortic valve disease. Similarly, aortic stenosis is not typically linked with complete heart block, although it can cause reversed splitting of S2. Giant V waves are not observed in complete heart block, but they suggest tricuspid regurgitation. Reversed splitting of S2 is also not a defining feature of complete heart block, but it can be found in aortic stenosis, hypertrophic cardiomyopathy, and left bundle branch block. It is important to note that murmurs may also be present in complete heart block due to concomitant valve disease.

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      • Cardiovascular Health
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  • Question 25 - You assess a 63-year-old man who has recently been released from a hospital...

    Incorrect

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

      Your Answer:

      Correct Answer: Add bisoprolol

      Explanation:

      The use of carvedilol and bisoprolol has been proven to decrease mortality in stable heart failure patients, while there is no evidence to support the use of other beta-blockers. NICE guidelines suggest that all individuals with heart failure should be prescribed both an ACE-inhibitor and a beta-blocker.

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

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      • Cardiovascular Health
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  • Question 26 - A 32-year-old man complains of palpitations.
    Select from the list the single situation in...

    Incorrect

    • A 32-year-old man complains of palpitations.
      Select from the list the single situation in which palpitations will most likely need urgent further investigation.

      Your Answer:

      Correct Answer: Palpitations accompanied by syncope or near syncope

      Explanation:

      Understanding Palpitations and When to Seek Medical Attention

      Palpitations are a common occurrence that can be described as an abnormally perceived heartbeat. While they are usually benign, they can be frightening. A risk stratification system has been developed to determine when urgent referral is necessary. This includes palpitations during exercise, palpitations with syncope or near syncope, a family history of sudden cardiac death or inheritable cardiac conditions, high degree atrioventricular block, and high-risk structural heart disease. However, a history of hypertension is not an indication for urgent referral. Ventricular extrasystoles on an ECG are likely benign unless there is a family history or known structural heart disease. Recurrent episodes of the heart beating fast may indicate a tachyarrhythmia and require routine referral. A normal ECG also warrants routine referral, except for second- and third-degree atrioventricular block, which require urgent referral. It is important to understand when to seek medical attention for palpitations to ensure proper care and treatment.

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      • Cardiovascular Health
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  • Question 27 - 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 28 - An 18-year-old patient visits his General Practitioner with worries about the appearance of...

    Incorrect

    • An 18-year-old patient visits his General Practitioner with worries about the appearance of his chest wall. He is generally healthy but mentions that his father passed away 10 years ago due to heart problems. Upon examination, he is 195 cm tall (>99th centile) and slender, with pectus excavatum and arachnodactyly. The doctor suspects that he may have Marfan syndrome. What is the most prevalent cardiovascular abnormality observed in adults with Marfan syndrome? Choose ONE answer only.

      Your Answer:

      Correct Answer: Aortic root dilatation

      Explanation:

      Cardiac Abnormalities in Marfan Syndrome

      Marfan syndrome is an inherited connective tissue disorder that affects various systems in the body. The most common cardiac complication is aortic root dilatation, which occurs in 70% of patients. Mitral valve prolapse is the second most common abnormality, affecting around 60% of patients. Beta-blockers can help reduce the rate of aortic dilatation and the risk of rupture. Aortic dissection, although not the most common abnormality, is a major diagnostic criterion of Marfan syndrome and can result from weakening of the aortic media due to root dilatation. Aortic regurgitation is less common than mitral regurgitation but can occur due to progressive aortic root dilatation and connective tissue abnormalities. Mitral annular calcification is more frequent in Marfan syndrome than in the general population but is not included in the diagnostic criteria.

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      • Cardiovascular Health
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  • Question 29 - A 38-year-old man suffers a myocardial infarction (MI) and is prescribed aspirin, atorvastatin,...

    Incorrect

    • A 38-year-old man suffers a myocardial infarction (MI) and is prescribed aspirin, atorvastatin, ramipril and bisoprolol upon discharge. After a month, he experiences some muscle aches and undergoes routine blood tests at the clinic. His serum creatine kinase (CK) activity is found to be 650 u/l (normal range 30–300 u/l). What is the probable reason for the elevated CK levels in this individual?

      Your Answer:

      Correct Answer: Effect of statin therapy

      Explanation:

      Interpreting Elevated CK Levels in a Post-MI Patient on Statin Therapy

      When a patient complains of symptoms while on statin therapy, it is reasonable to check their CK levels. An elevated level suggests statin-induced myopathy, and the statin should be discontinued. However, if the patient doesn’t complain of further chest pain suggestive of another MI, CK is no longer routinely measured as a cardiac marker. Heavy exercise should also be avoided, and CK levels usually return to baseline within 72 hours post-MI. While undiagnosed hypothyroidism can cause a rise in CK, it is less likely than statin-induced myopathy, and other clinical features of hypothyroidism are not mentioned in the scenario.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 30 - 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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