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Question 1
Incorrect
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You assess a 52-year-old patient with hypertension who has been taking 2.5mg of ramipril for a month. He reports experiencing a persistent tickly cough that is causing him to lose sleep at night. Despite this, his blood pressure is now under control.
What recommendations would you provide to him?Your Answer: Stop the ramipril and prescribe 5mg amlodipine
Correct Answer: Stop the ramipril and prescribe candesartan
Explanation:When patients are unable to tolerate ACE inhibitors due to the common side effect of a dry, persistent cough, angiotensin-receptor blockers (ARBs) should be considered as an alternative. For individuals under the age of 55 who experience intolerance to ACE inhibitors, prescribing medications such as candesartan, an ARB, may be the next appropriate step.
Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of calcium channel blockers or thiazide-like diuretics in addition to ACE inhibitors or angiotensin receptor blockers.
Lifestyle changes are also important in managing hypertension. Patients should aim for a low salt diet, reduce caffeine intake, stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more, and lose weight.
Treatment for hypertension depends on the patient’s blood pressure classification. For stage 1 hypertension with ABPM/HBPM readings of 135/85 mmHg or higher, treatment is recommended for patients under 80 years old with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For stage 2 hypertension with ABPM/HBPM readings of 150/95 mmHg or higher, drug treatment is recommended regardless of age.
The first-line treatment for patients under 55 years old or with a background of type 2 diabetes mellitus is an ACE inhibitor or angiotensin receptor blocker. Calcium channel blockers are recommended for patients over 55 years old or of black African or African-Caribbean origin. If a patient is already taking an ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker or thiazide-like diuretic can be added.
If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, NICE recommends seeking expert advice or adding a fourth drug. Blood pressure targets vary depending on age, with a target of 140/90 mmHg for patients under 80 years old and 150/90 mmHg for patients over 80 years old. Direct renin inhibitors, such as Aliskiren, may be used in patients who are intolerant of other antihypertensive drugs, but their role is currently limited.
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This question is part of the following fields:
- Cardiovascular Health
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Question 2
Incorrect
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A 55-year-old man is concerned about experiencing palpitations. He reports that they occur twice a day and are fast and irregular, with a possible association with alcohol consumption. He denies any chest pain or fainting episodes. On examination, his cardiovascular symptoms are normal, with a pulse of 72/min and a blood pressure of 116/78 mmHg. Blood tests and a 12-lead ECG are unremarkable. What would be the most suitable course of action for managing this patient's condition?
Your Answer: Arrange an echocardiogram
Correct Answer: Arrange a Holter monitor
Explanation:If a patient experiences palpitations, the first step in investigating the issue should be to conduct a Holter monitor test after conducting initial blood tests and an ECG. Palpitations are often indicative of an arrhythmia, such as atrial fibrillation, and it is important to conduct further investigations to rule out this possibility.
Holter monitoring is the recommended first-line investigation to capture any episodes of arrhythmia. Since the patient experiences these episodes daily, a 24-hour monitoring period is appropriate. However, a troponin test is not necessary as there is no chest pain, and an echocardiogram is not warranted as there are no indications of heart failure.
If the Holter monitoring results are normal and the patient continues to experience symptoms, an external loop recorder may be considered.
Investigating Palpitations: Identifying Possible Causes and Capturing Episodic Arrhythmias
Palpitations are a common symptom that can be caused by various factors such as arrhythmias, stress, and increased awareness of normal heartbeats. To investigate the underlying cause of palpitations, first-line investigations include a 12-lead ECG, thyroid function tests, urea and electrolytes, and a full blood count. However, these investigations may not capture episodic arrhythmias, which are often missed during a short ECG recording.
To capture episodic arrhythmias, the most common investigation is Holter monitoring. This portable battery-operated device continuously records ECG from 2-3 leads for 24 hours or longer if symptoms are less than daily. Patients are asked to keep a diary to record any symptomatic palpitations, which can later be compared to the rhythm strip at the time of the symptoms. At the end of the monitoring, a report is generated summarizing heart rate, arrhythmias, and changes in ECG waveform.
If no abnormality is found on the Holter monitor and symptoms persist, other options include an external loop recorder or an implantable loop recorder. These investigations can help identify the underlying cause of palpitations and guide appropriate management.
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This question is part of the following fields:
- Cardiovascular Health
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Question 3
Correct
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A 52-year-old man comes to the clinic four weeks after being released from the hospital. He was admitted due to chest pain and was given thrombolytic therapy for a heart attack. Today, he experienced significant swelling of his tongue and face. Which medication is the most probable cause of this reaction?
Your Answer: Ramipril
Explanation:Drug-induced angioedema is most frequently caused by 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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This question is part of the following fields:
- Cardiovascular Health
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Question 4
Incorrect
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A 28-year-old man walks into the General Practice Surgery without an appointment, complaining of central chest pain radiating to his jaw.
On examination, he is agitated. His respiratory rate is 26 breaths per minute (normal range 12–20) and his pulse is 130 beats per minute (normal range 60–100).
An electrocardiogram (ECG) confirms an ST-elevation myocardial infarction (STEMI). An accompanying friend suspects that the patient took a drug around 30 minutes previously but is unsure what it was.
Which of the following drugs is most likely to be responsible for this patient's symptoms?Your Answer: Cannabis
Correct Answer: Cocaine
Explanation:Cardiovascular Risks Associated with Substance Abuse
Substance abuse can have significant impacts on cardiovascular health. Chronic cocaine use, for example, is a major risk factor for acute myocardial ischaemia, which can cause central chest pain, tachycardia, and other symptoms. Alcohol consumption, particularly binge-drinking, is also considered a cardiovascular risk factor, although it is not as strongly correlated with immediate effects as cocaine. Amphetamine and ecstasy intoxication can cause symptoms such as tachycardia, hyperthermia, and hypertension, and there have been reports of myocardial infarction associated with chronic use. Cannabis use can also cause tachycardia and other symptoms, but is rarely associated with MI. Overall, substance abuse can have serious consequences for cardiovascular health, particularly in men who are more likely to engage in drug use and dependence.
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This question is part of the following fields:
- Cardiovascular Health
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Question 5
Incorrect
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A 65-year-old man with a history of depression and lumbar spinal stenosis presents with a swollen and painful left calf. He is seen in the DVT clinic and found to have a raised D-dimer. As a result, he undergoes a Doppler scan which reveals a proximal deep vein thrombosis. Despite being active and otherwise healthy, the patient has not had any recent surgeries or prolonged periods of immobility. He is initiated on a direct oral anticoagulant.
What is the appropriate duration of treatment for this patient?Your Answer:
Correct Answer: 6 months
Explanation:For provoked cases of venous thromboembolism, such as those following recent surgery, warfarin treatment is typically recommended for a duration of three months. However, for unprovoked cases, where the cause is unknown, a longer duration of six months is typically recommended.
Deep vein thrombosis (DVT) is a serious condition that requires prompt diagnosis and management. The National Institute for Health and Care Excellence (NICE) updated their guidelines in 2020, recommending the use of direct oral anticoagulants (DOACs) as first-line treatment for most people with VTE, including as interim anticoagulants before a definite diagnosis is made. They also recommend the use of DOACs in patients with active cancer, as opposed to low-molecular weight heparin as was previously recommended. Routine cancer screening is no longer recommended following a VTE diagnosis.
If a patient is suspected of having a DVT, a two-level DVT Wells score should be performed to assess the likelihood of the condition. If a DVT is ‘likely’ (2 points or more), a proximal leg vein ultrasound scan should be carried out within 4 hours. If the result is positive, then a diagnosis of DVT is made and anticoagulant treatment should start. If the result is negative, a D-dimer test should be arranged. If a proximal leg vein ultrasound scan cannot be carried out within 4 hours, a D-dimer test should be performed and interim therapeutic anticoagulation administered whilst waiting for the proximal leg vein ultrasound scan (which should be performed within 24 hours).
The cornerstone of VTE management is anticoagulant therapy. The big change in the 2020 guidelines was the increased use of DOACs. Apixaban or rivaroxaban (both DOACs) should be offered first-line following the diagnosis of a DVT. Instead of using low-molecular weight heparin (LMWH) until the diagnosis is confirmed, NICE now advocate using a DOAC once a diagnosis is suspected, with this continued if the diagnosis is confirmed. If neither apixaban or rivaroxaban are suitable, then either LMWH followed by dabigatran or edoxaban OR LMWH followed by a vitamin K antagonist (VKA, i.e. warfarin) can be used.
All patients should have anticoagulation for at least 3 months. Continuing anticoagulation after this period is partly determined by whether the VTE was provoked or unprovoked. If the VTE was provoked, the treatment is typically stopped after the initial 3 months (3 to 6 months for people with active cancer). If the VTE was
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This question is part of the following fields:
- Cardiovascular Health
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Question 6
Incorrect
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You have a phone review scheduled with Mrs. Johansson, a 55-year-old woman who has recently been diagnosed with hypertension, which had been detected during a routine check-up. Subsequent ambulatory home blood pressure monitoring showed an average home BP of 148/84 mmHg.
You arranged an ECG, urine albumin-creatinine ratio (ACR), and some blood tests, and scheduled the appointment to discuss the findings. The ACR and blood tests are within normal limits. The ECG shows sinus rhythm with a rate of 70 beats per minute. You entered her cholesterol results into a cardiovascular risk calculator, which estimates a 10-year CV risk of 6.5%.
What is the appropriate management plan for her hypertension?Your Answer:
Correct Answer: Lifestyle advice, and discuss commencing a calcium-channel blocker
Explanation:Consider medication for stage 1 hypertension in patients aged 60 or under, but for those aged 55 or over, a calcium channel blocker is the first-line option. Lifestyle advice should also be given. Referral to cardiology is not necessary at this stage.
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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This question is part of the following fields:
- Cardiovascular Health
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Question 7
Incorrect
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A 44-year-old man has an irregular tachycardia with a ventricular rate of 130. He played in a football match the previous day and consumed 28 units of alcohol on the evening of the match. On examination his blood pressure is 95/50 mmHg.
Select from the list the single most likely diagnosis.Your Answer:
Correct Answer: Atrial fibrillation
Explanation:Common Cardiac Arrhythmias and Their Characteristics
Acute atrial fibrillation is characterized by a sudden onset within the past 48 hours and may be triggered by excessive alcohol or caffeine intake. An ECG is necessary for diagnosis. Atrial flutter is less common than atrial fibrillation and typically presents with a rapid, irregular or regular pulse with a ventricular rate of approximately 150 beats per minute. Extrasystoles are extra heartbeats that disrupt the normal rhythm of the heart and can originate from either the atria or ventricles. Sinus arrhythmia is a common occurrence in children and young adults and involves cyclic changes in heart rate during breathing. Sinus tachycardia is a physiological response to various stimuli such as fever, anxiety, pain, exercise, and hyperthyroidism, and is characterized by a regular heart rate of over 100 beats per minute.
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This question is part of the following fields:
- Cardiovascular Health
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Question 8
Incorrect
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A 67-year-old man presents with shortness of breath.
An ECG shows atrial fibrillation (AF).
He takes digoxin, furosemide, and lisinopril.
What further drug would improve this patient's outcome?Your Answer:
Correct Answer: Abciximab
Explanation:Prophylactic Therapy for AF Patients with Heart Failure
The risk of embolic events in patients with heart failure and AF is high, with the risk of stroke increasing up to five-fold in non-rheumatic AF. The most appropriate prophylactic therapy for these patients is with an anticoagulant, such as warfarin.
According to studies, for every 1,000 patients with AF who are treated with warfarin for one year, 30 strokes are prevented at the expense of six major bleeds. On the other hand, for every 1,000 patients with AF who are treated with aspirin for one year, only 12.5 strokes are prevented at the expense of six major bleeds.
It is important to note that NICE guidelines on Atrial fibrillation (CG180) recommend warfarin, not aspirin, as the preferred prophylactic therapy for AF patients with heart failure.
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This question is part of the following fields:
- Cardiovascular Health
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Question 9
Incorrect
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A 65-year-old man with a history of hypertension and dyslipidaemia visits the clinic. His wife is worried about his increasing forgetfulness. He frequently loses things around the house and struggles to find his way back home when he goes to the shops alone. What characteristic would strongly suggest vascular dementia?
Your Answer:
Correct Answer: Stepwise deterioration in symptoms with a clearly measurable difference between steps and no reversal
Explanation:Understanding Vascular Dementia
Vascular dementia is a type of cognitive decline that includes multi-infarct dementia and other forms of intellectual deterioration in individuals at high risk of atherosclerosis. Unlike Alzheimer’s, it is characterized by a stepwise progression, although it may also present as a steadily progressive dementia. A history of risk factors such as transient ischemic attacks (TIAs), stroke, hypertension, smoking, and hypercholesterolemia can raise suspicion of vascular dementia.
Aggression without significant short-term memory loss is more commonly associated with frontal lobe dementia, while Parkinsonian features are typical of Lewy body dementia. Understanding the different types of dementia and their associated symptoms can help individuals and their loved ones better manage the condition and seek appropriate medical care.
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This question is part of the following fields:
- Cardiovascular Health
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Question 10
Incorrect
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A 50-year-old woman, who has a history of atrial fibrillation and is receiving warfarin and digoxin, tells you that she has been feeling low lately and has been self medicating with St John's wort which she bought from a health store.
Which of the following interactions can be anticipated between St John's Wort and her current medication?Your Answer:
Correct Answer: INR is likely to be reduced
Explanation:St John’s Wort and Medication Interactions
St John’s wort is a popular natural remedy for depressive symptoms. However, it is important to note that it is a liver enzyme inducer, which can lead to interactions with other medications. For example, St John’s wort may reduce the efficacy of warfarin, a blood thinner, requiring an increased dose to maintain the desired level of anticoagulation. It may also reduce the efficacy of digoxin, a medication used to treat heart failure. Therefore, it is important to discuss the use of St John’s wort with a healthcare provider before taking it in combination with other medications. By doing so, potential interactions can be identified and managed appropriately.
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This question is part of the following fields:
- Cardiovascular Health
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Question 11
Incorrect
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You are assessing a 67-year-old woman with longstanding varicose veins. A couple of weeks ago, she experienced pain and redness around one of them, which resolved after using ibuprofen gel for a few weeks. Upon examination, her legs appear normal except for the varicose veins, and she has normal distal pulses. Based on current NICE guidelines, what is the most suitable next step in management?
Your Answer:
Correct Answer: Routine referral to vascular services
Explanation:Patients with varicose veins and a history of superficial thrombophlebitis should be referred for routine referral to vascular services according to NICE guidance. This condition is usually self-limiting but has a high likelihood of recurrence without treatment. Dermatology is not involved in this condition, and ABPI is usually used in the context of peripheral arterial disease or compression bandaging. Class 2 compression stockings are used in the treatment of varicose veins without complications in primary care.
Understanding Varicose Veins
Varicose veins are enlarged and twisted veins that occur when the valves in the veins become weak or damaged, causing blood to flow backward and pool in the veins. They are most commonly found in the legs and can be caused by various factors such as age, gender, pregnancy, obesity, and genetics. While many people seek treatment for cosmetic reasons, others may experience symptoms such as aching, throbbing, and itching. In severe cases, varicose veins can lead to skin changes, bleeding, superficial thrombophlebitis, and venous ulceration.
To diagnose varicose veins, a venous duplex ultrasound is typically performed to detect retrograde venous flow. Treatment options vary depending on the severity of the condition. Conservative treatments such as leg elevation, weight loss, regular exercise, and compression stockings may be recommended for mild cases. However, patients with significant or troublesome symptoms, skin changes, or a history of bleeding or ulcers may require referral to a specialist for further evaluation and treatment. Possible treatments include endothermal ablation, foam sclerotherapy, or surgery.
In summary, varicose veins are a common condition that can cause discomfort and cosmetic concerns. While many cases do not require intervention, it is important to seek medical attention if symptoms or complications arise. With proper diagnosis and treatment, patients can manage their condition and improve their quality of life.
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This question is part of the following fields:
- Cardiovascular Health
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Question 12
Incorrect
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An 80-year-old man comes to the clinic complaining of occasional palpitations without any accompanying chest pain, shortness of breath, or lightheadedness. He has no notable medical history and is not taking any medications at present. Physical examination and vital signs are normal except for an irregular heartbeat, which is later diagnosed as atrial fibrillation. What is the suggested preventive therapy for a stroke?
Your Answer:
Correct Answer: Consider an anticoagulant
Explanation:Anticoagulation must be taken into account for individuals with a CHA2DS2-VASC score of 1 or higher if they are male, and a score of 2 or higher if they are female. In this case, the gentleman’s CHA2DS2-VASC score is 1, indicating that he should be considered for anticoagulation after assessing his HAS-BLED score. It is important to note that if his HAS-BLED score is 3 or higher, alternative options to anticoagulation should be considered. Beta-blockers, aspirin, and clopidogrel are not recommended for primary prevention against cerebrovascular accidents. It is incorrect to assume that no treatment is necessary, as the CHA2DS2-VASC score indicates a need for consideration of 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.
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This question is part of the following fields:
- Cardiovascular Health
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Question 13
Incorrect
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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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This question is part of the following fields:
- Cardiovascular Health
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Question 14
Incorrect
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A 75-year-old male comes to the Emergency Department complaining of increased swelling in his right leg. He has a medical history of right-sided heart failure. During the examination, his right calf is found to be 3 cm larger than his left and he has bilateral pitting oedema up to the knee. A positive D-dimer result prompts the initiation of apixaban. However, an ultrasound scan of his leg comes back negative.
What would be the most suitable course of action?Your Answer:
Correct Answer: Stop anticoagulation and repeat scan in 1 week
Explanation:If a D-dimer test is positive but an ultrasound scan for possible deep vein thrombosis (DVT) is negative, the recommended course of action is to stop anticoagulation and repeat the scan in one week. It is not appropriate to simply discharge the patient with worsening advice, as a follow-up scan is necessary to ensure that a clot has not been missed. Continuing anticoagulation would only be appropriate if the scan had shown a positive result. It is not recommended to continue anticoagulation for three or six months, as these are management strategies for a confirmed DVT that has been detected by a positive ultrasound scan.
Deep vein thrombosis (DVT) is a serious condition that requires prompt diagnosis and management. The National Institute for Health and Care Excellence (NICE) updated their guidelines in 2020, recommending the use of direct oral anticoagulants (DOACs) as first-line treatment for most people with VTE, including as interim anticoagulants before a definite diagnosis is made. They also recommend the use of DOACs in patients with active cancer, as opposed to low-molecular weight heparin as was previously recommended. Routine cancer screening is no longer recommended following a VTE diagnosis.
If a patient is suspected of having a DVT, a two-level DVT Wells score should be performed to assess the likelihood of the condition. If a DVT is ‘likely’ (2 points or more), a proximal leg vein ultrasound scan should be carried out within 4 hours. If the result is positive, then a diagnosis of DVT is made and anticoagulant treatment should start. If the result is negative, a D-dimer test should be arranged. If a proximal leg vein ultrasound scan cannot be carried out within 4 hours, a D-dimer test should be performed and interim therapeutic anticoagulation administered whilst waiting for the proximal leg vein ultrasound scan (which should be performed within 24 hours).
The cornerstone of VTE management is anticoagulant therapy. The big change in the 2020 guidelines was the increased use of DOACs. Apixaban or rivaroxaban (both DOACs) should be offered first-line following the diagnosis of a DVT. Instead of using low-molecular weight heparin (LMWH) until the diagnosis is confirmed, NICE now advocate using a DOAC once a diagnosis is suspected, with this continued if the diagnosis is confirmed. If neither apixaban or rivaroxaban are suitable, then either LMWH followed by dabigatran or edoxaban OR LMWH followed by a vitamin K antagonist (VKA, i.e. warfarin) can be used.
All patients should have anticoagulation for at least 3 months. Continuing anticoagulation after this period is partly determined by whether the VTE was provoked or unprovoked. If the VTE was provoked, the treatment is typically stopped after the initial 3 months (3 to 6 months for people with active cancer). If the VTE was
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This question is part of the following fields:
- Cardiovascular Health
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Question 15
Incorrect
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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:
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
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This question is part of the following fields:
- Cardiovascular Health
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Question 16
Incorrect
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A 65-year-old man presented, having had an episode of right-sided weakness that lasted 10 minutes a fortnight earlier and fully resolved.
Examination reveals that he is in atrial fibrillation.
Assuming he remains in atrial fibrillation which of the following is the most appropriate management regime?Your Answer:
Correct Answer: No antithrombotic treatment indicated
Explanation:Thromboprophylaxis for High Risk Stroke Patients
This patient is at high risk for future stroke and requires anticoagulation with warfarin. To assess the risk of bleeding and stroke, it is important to calculate the HASBLED and CHADS-VASc scores. The CHADS-VASc score takes into account factors such as congestive heart failure, hypertension, age, diabetes, stroke history, vascular disease, and sex. If the score is 1 or higher, oral anticoagulation should be considered. If the score is 0, no anticoagulation is needed. If the score is 1 but the only point is for female gender, it is treated as a score of 0. In this case, the patient’s CHADS-VASc score is 2, indicating a need for anticoagulation. The target range for INR is 2-3, with a target INR of 2.5.
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This question is part of the following fields:
- Cardiovascular Health
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Question 17
Incorrect
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Which Antihypertensive medication is banned for use by professional athletes?
Your Answer:
Correct Answer: Doxazosin
Explanation:Prohibited Substances in Sports
Beta-blockers and diuretics are among the substances prohibited in certain sports. In billiards and archery, the use of beta-blockers is not allowed as they can enhance performance by reducing anxiety and tremors. On the other hand, diuretics are generally prohibited as they can be used as masking agents to hide the presence of other banned substances. It is important to note that diuretics can be found in some combination products, such as Cozaar-Comp which contains hydrochlorothiazide. Athletes should be aware of the substances they are taking and ensure that they are not violating any anti-doping regulations.
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This question is part of the following fields:
- Cardiovascular Health
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Question 18
Incorrect
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A 75-year-old man with a history of diabetes, hypertension, hypercholesterolaemia and previous myocardial infarction presents to his GP with intermittent abdominal pain that he has been experiencing for two months. The pain is dull in nature and radiates to his lower back. During examination, a pulsatile expansile mass is detected in the central abdomen. The patient had undergone an abdominal ultrasound 6 months ago which showed an abdominal aortic diameter of 5.1 cm. The GP repeats the ultrasound and refers the patient to the vascular clinic. The vascular surgeon reviews the patient's ultrasound report which shows no focal pancreatic, liver or gallbladder disease, trace free fluid, a 5.4 cm diameter abdominal aorta, no biliary duct dilation, and normal-sized and mildly echogenic kidneys.
What aspect of the patient's medical history suggests that surgery may be necessary?Your Answer:
Correct Answer: Abdominal pain
Explanation:If a patient experiences abdominal pain, it is likely that they have a symptomatic AAA which poses a high risk of rupture. In such cases, surgical intervention, specifically endovascular repair (EVAR), is necessary rather than relying on medical treatment or observation. The abdominal aortic diameter must be greater than 5.5cm to be classified as high rupture risk, which is a close call. The presence of trace free fluid is generally considered normal. Conservative measures, such as quitting smoking, should be taken to address cardiovascular risk factors. An AAA’s velocity of growth should be monitored, and a high-risk AAA would only be indicated if there is an increase of more than 1 cm per year. Ultimately, the decision to proceed with elective surgery is a complex one that should be made in consultation with the patient and surgeon.
Abdominal aortic aneurysm (AAA) is a condition that often develops without any symptoms. However, a ruptured AAA can be fatal, so it is important to screen patients for this condition. Screening involves a single abdominal ultrasound for males aged 65. The results of the screening are interpreted based on the width of the aorta. If the width is less than 3 cm, no further action is needed. If the width is between 3-4.4 cm, the patient should be rescanned every 12 months. If the width is between 4.5-5.4 cm, the patient should be rescanned every 3 months. If the width is 5.5 cm or greater, the patient should be referred to vascular surgery within 2 weeks for probable intervention.
For patients with a low risk of rupture (asymptomatic, aortic diameter < 5.5cm), abdominal ultrasound surveillance should be conducted on the time-scales outlined above. Additionally, cardiovascular risk factors should be optimized, such as quitting smoking. For patients with a high risk of rupture (symptomatic, aortic diameter >=5.5cm or rapidly enlarging), referral to vascular surgery for probable intervention should occur within 2 weeks. Treatment options include elective endovascular repair (EVAR) or open repair if unsuitable. EVAR involves placing a stent into the abdominal aorta via the femoral artery to prevent blood from collecting in the aneurysm. However, a complication of EVAR is an endo-leak, where the stent fails to exclude blood from the aneurysm, and usually presents without symptoms on routine follow-up.
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This question is part of the following fields:
- Cardiovascular Health
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Question 19
Incorrect
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A 78-year-old gentleman visited his GP last week and was referred for 24 hour ambulatory blood pressure monitoring. The results showed a daytime average of 144/82 mmHg. He is currently taking amlodipine 10 mg once a day and ramipril 10 mg once a day. What would be the best course of action for managing this patient?
Your Answer:
Correct Answer: Continue current therapy
Explanation:ABPM vs Solitary Clinic Blood Pressure
Note the difference between a solitary clinic blood pressure and ABPM. ABPM stands for ambulatory blood pressure monitoring, which is a method of measuring blood pressure over a 24-hour period. This is different from a solitary clinic blood pressure, which is taken in a medical setting at a single point in time.
For patients over the age of 80, their daytime average ABPM or average HBPM (hospital blood pressure monitoring) blood pressure should be less than 145/85 mmHg. This is according to NICE guidelines, which state that for people under 80 years old, the daytime average ABPM or average HBPM blood pressure should be lower than 135/85 mmHg.
It’s important to note that ABPM targets are different from clinic BP targets. This is because ABPM provides a more accurate and comprehensive picture of a patient’s blood pressure over a 24-hour period, rather than just a single reading in a medical setting. By using ABPM, healthcare professionals can better monitor and manage a patient’s blood pressure, especially for those over the age of 80.
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This question is part of the following fields:
- Cardiovascular Health
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Question 20
Incorrect
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A 50-year-old woman has a diastolic murmur best heard in the upper-left 2nd intercostal space.
What single condition would be part of the differential diagnosis?
Your Answer:
Correct Answer: Aortic regurgitation
Explanation:Differentiating Heart Murmurs: Characteristics and Causes
Heart murmurs are abnormal sounds heard during the cardiac cycle. They can be caused by a variety of conditions, including valve abnormalities, septal defects, and physiological factors. Here are some characteristics and causes of common heart murmurs:
Aortic Regurgitation: This produces a low-intensity early diastolic decrescendo murmur, best heard in the aortic area. The backflow of blood across the aortic valve causes the murmur.
Aortic Stenosis: This produces a mid-systolic ejection murmur in the aortic area. It radiates into the neck over the two carotid arteries. The most common cause is calcified aortic valves due to ageing, followed by congenital bicuspid aortic valves.
Mitral Regurgitation: This murmur is best heard at the apex. In the presence of incompetent mitral valve, the pressure in the left ventricle becomes greater than that in the left atrium at the start of isovolumic contraction, which corresponds to the closing of the mitral valve (S1).
Physiological Murmur: This is a low-intensity murmur that mainly occurs in children. It can occur in adults particularly if there is anaemia or a fever. It is caused by increased blood flow through the aortic valves.
Ventricular Septal Defect: This produces a pansystolic murmur that starts at S1 and extends up to S2. In a VSD the murmur is usually best heard over the left lower sternal border (tricuspid area) with radiation to the right lower sternal border. This is the area overlying the VSD.
Understanding the characteristics and causes of different heart murmurs can aid in their diagnosis and management.
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This question is part of the following fields:
- Cardiovascular Health
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Question 21
Incorrect
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You are evaluating an 80-year-old patient who has recently been diagnosed with heart failure. Her left ventricular ejection fraction is 55%. She has been experiencing orthopnoea and ankle swelling. The cardiology team has referred her to you for medication initiation.
During the assessment, her vital signs are blood pressure 120/80 mmHg and heart rate 82/min.
What should be the initial consideration in her management?Your Answer:
Correct Answer: Furosemide
Explanation:Furosemide is the appropriate choice for managing symptoms in individuals with heart failure with preserved ejection fraction using loop diuretics. Spironolactone is not recommended for this purpose. In cases of heart failure with reduced ejection fraction, mineralocorticoid receptor antagonists should be considered along with an ACE inhibitor (or ARB) and beta-blocker if symptoms persist.
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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This question is part of the following fields:
- Cardiovascular Health
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Question 22
Incorrect
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A 58-year-old man comes to his GP complaining of headaches and blurred vision that have been present for two days. He has been taking amlodipine 5 mg, which was prescribed at the same clinic two weeks ago. During the examination, his blood pressure is measured at 190/115 mmHg. Although his cardiovascular examination is unremarkable, retinal hemorrhages are observed during fundoscopy, but no papilledema is present. What is the best course of action for this patient?
Your Answer:
Correct Answer: Refer for urgent specialist care on the same day
Explanation:NICE Guidelines for Referral to Specialist Care for Hypertension
According to NICE guidelines, patients with accelerated hypertension or suspected phaeochromocytoma should be referred to specialist care on the same day. Accelerated hypertension is defined as having a blood pressure usually higher than 180/120 mmHg with signs of papilloedema and/or retinal haemorrhage. Suspected phaeochromocytoma is characterized by labile or postural hypotension, headache, palpitations, pallor, and diaphoresis.
It is important to note that if a patient presents with a blood pressure higher than 180/120 mmHg, it is crucial to examine their fundi and check for the presence or absence of papilloedema or retinal haemorrhages. Additionally, healthcare professionals should consider the need for specialist investigations in patients with signs and symptoms suggesting a secondary cause of hypertension. By following these guidelines, healthcare professionals can ensure that patients receive appropriate and timely care for their hypertension.
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This question is part of the following fields:
- Cardiovascular Health
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Question 23
Incorrect
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A 40-year-old male smoker with a family history of hypertension has persistently high resting blood pressure.
Ambulatory testing revealed a level of 146/84 mmHg. He has no signs of end organ damage on standard testing.
According to the latest NICE guidance (NG136), what would be your most appropriate course of action?Your Answer:
Correct Answer: Start treatment with a calcium antagonist
Explanation:Understanding the Importance of NICE Guidance on Hypertension
This passage discusses the latest NICE guidance on hypertension and its importance in evaluating the long-term balance of treatment benefit and risks for adults under 40 with hypertension. However, it also highlights the criticism that the guidance has received from some clinicians, particularly regarding the use of ambulatory and home blood pressure monitoring. It is important to have a balanced view and be aware of other guidelines and consensus opinions in medicine. While AKT questions may not contradict NICE guidance, it is essential to consider the bigger picture and not solely rely on the latest guidance. Remember that the questions test your knowledge of national guidance and consensus opinion. Proper understanding of NICE guidance on hypertension is crucial, but it is equally important to have a broader perspective on the matter.
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This question is part of the following fields:
- Cardiovascular Health
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Question 24
Incorrect
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A 49-year-old male with type 2 diabetes presents for review. He has a past medical history of hypertension, migraine, and obesity (BMI is 38). Currently, he takes metformin 1 g BD and ramipril 5 mg OD for blood pressure control. His latest HbA1c is 50 mmol/mol, and his total cholesterol is 5.2 with an LDL cholesterol of 3.5. His QRisk2 score is 21%.
During the consultation, you discuss the addition of lipid-lowering medication to reduce his cardiovascular risk, especially in light of his recently treated hypertension. You both agree that starting him on Atorvastatin 20 mg at night is an appropriate treatment for primary prevention of cardiovascular disease.
Before prescribing the medication, you review his latest blood results, which show normal full blood count, renal function, and thyroid function. However, his liver function tests reveal an ALT of 106 IU/L (<60) and an ALP of 169 IU/L (20-200). Bilirubin levels are within normal limits.
Upon further investigation, you discover that the ALT rise has persisted since his first blood tests at the surgery over four years ago. However, the liver function results have remained stable over this time, showing no significant variation from the current values. A liver ultrasound done two years ago reports some evidence of fatty infiltration only.
What is the most appropriate management strategy for this patient?Your Answer:
Correct Answer: Atorvastatin 20 mg nocte can be initiated and repeat liver function tests should be performed within the first three months of use
Explanation:Liver Function and Statin Therapy
Liver function should be assessed before starting statin therapy. If liver transaminases are three times the upper limit of normal, statins should not be initiated. However, if the liver enzymes are elevated but less than three times the upper limit of normal, statin therapy can be used. It is important to repeat liver function tests within the first three months of treatment and then at 12 months, as well as if a dose increase is made or if clinically indicated.
In the case of a modest ALT elevation due to fatty deposition in the liver, statin therapy can still be beneficial for primary prevention, especially if the patient’s Qrisk2 score is over 10%. Mild derangement in liver function is not uncommon in overweight type 2 diabetics. The patient can be treated with the usual NICE-guided primary prevention dose of atorvastatin, which is 20 mg nocte. A higher dose or alternative statin may be required in the future, depending on the patient’s response to the initial treatment and lifestyle modifications. The slight ALT rise doesn’t necessarily require a lower statin dose.
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This question is part of the following fields:
- Cardiovascular Health
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Question 25
Incorrect
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You are contemplating prescribing enalapril for a patient with recently diagnosed heart failure. What are the most typical side-effects of angiotensin-converting enzyme inhibitors?
Your Answer:
Correct Answer: Cough + anaphylactoid reactions + hyperkalaemia
Explanation: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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This question is part of the following fields:
- Cardiovascular Health
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Question 26
Incorrect
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A 65-year-old male is being evaluated for hypertension associated with type 2 diabetes.
Currently, he is taking aspirin 75 mg daily, amlodipine 10 mg daily, and atorvastatin 20 mg daily. However, his blood pressure remains consistently around 160/92 mmHg.
What antihypertensive medication would you recommend adding to improve this patient's hypertension?Your Answer:
Correct Answer: Ramipril
Explanation:Hypertension Management in Type 2 Diabetes
This patient with type 2 diabetes has poorly controlled hypertension, but is currently tolerating his medication well. The recommended antihypertensive for diabetes is an ACE inhibitor, which can be combined with a calcium channel blocker like amlodipine. Beta-blockers should be avoided for routine hypertension treatment in diabetic patients. Methyldopa is used for hypertension during pregnancy, while moxonidine is used when other medications have failed. If blood pressure control is still inadequate, a thiazide diuretic can be added to the current regimen of ramipril and amlodipine. Proper management of hypertension is crucial in diabetic patients to prevent complications and improve overall health.
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This question is part of the following fields:
- Cardiovascular Health
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Question 27
Incorrect
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A 30-year-old woman complains of intermittent attacks of severe pain in her hands. These symptoms occur on exposure to cold. She describes her fingers becoming white and numb. Episodes last for 1-2 hours after which her fingers become blue, then red and painful. The examination is normal.
What is the single most likely diagnosis?
Your Answer:
Correct Answer: Raynaud’s disease
Explanation:Common Causes of Hand and Arm Symptoms
Raynaud’s Disease and Syndrome, Subclavian Artery Insufficiency, Carpal Tunnel Syndrome, Systemic Sclerosis, and Vibration White Finger are all potential causes of hand and arm symptoms. Raynaud’s Disease is the primary form of Raynaud’s Phenomenon and can be treated by avoiding triggers. Secondary Raynaud’s Phenomenon, or Raynaud’s Syndrome, is less common and may indicate an underlying connective tissue disorder. Subclavian Artery Insufficiency can cause arm claudication and other neurological symptoms. Carpal Tunnel Syndrome presents with pain, numbness, and tingling in specific fingers without vascular instability. Systemic Sclerosis, specifically CREST Syndrome, can cause calcinosis, Raynaud’s Phenomenon, oesophageal dysmotility, sclerodactyly, and telangiectasia. Vibration White Finger is caused by the use of vibrating tools and is another potential cause of secondary Raynaud’s Phenomenon in the hands.
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This question is part of the following fields:
- Cardiovascular Health
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Question 28
Incorrect
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A 55-year-old man visits your clinic to request a refill of his sildenafil prescription, which he has been taking for several years. Upon reviewing his medical history, you discover that he suffered a heart attack four months ago. What course of action should you take?
Your Answer:
Correct Answer: Do not prescribe as contraindicated
Explanation:Sildenafil use is not recommended for patients who have had a recent myocardial infarction or unstable angina, as stated in both the BNF and NICE guidelines. As the patient in this question had a myocardial infarction just 4 months ago, prescribing sildenafil is contraindicated. Therefore, the answer to this question is do not prescribe.
Phosphodiesterase type V inhibitors are medications used to treat erectile dysfunction and pulmonary hypertension. They work by increasing cGMP, which leads to relaxation of smooth muscles in blood vessels supplying the corpus cavernosum. The most well-known PDE5 inhibitor is sildenafil, also known as Viagra, which is taken about an hour before sexual activity. Other examples include tadalafil (Cialis) and vardenafil (Levitra), which have longer-lasting effects and can be taken regularly. However, these medications have contraindications, such as not being safe for patients taking nitrates or those with hypotension. They can also cause side effects such as visual disturbances, blue discolouration, and headaches. It is important to consult with a healthcare provider before taking PDE5 inhibitors.
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This question is part of the following fields:
- Cardiovascular Health
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Question 29
Incorrect
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A 68-year-old woman has weight loss and heat intolerance.
Investigations:
Free T4 32.9 pmol/L (9.8-23.1)
TSH <0.02 mU/L (0.35-5.50)
Free T3 11.1 pmol/L (3.5-6.5)
She is taking medication for atrial fibrillation, ischaemic heart disease and type 2 diabetes.
Which drug is most likely to be responsible for these results?Your Answer:
Correct Answer: Digoxin
Explanation:Amiodarone and Thyroid Function
Amiodarone is a medication commonly used to treat heart rhythm disorders. However, it can also cause abnormalities in thyroid function tests. This can result in both hypothyroidism and hyperthyroidism. Hypothyroidism may occur due to interference with the conversion of thyroxine (T4) to tri-iodothyronine (T3). On the other hand, hyperthyroidism may be caused by thyroiditis or the donation of iodine, as amiodarone contains a large amount of iodine.
Aside from thyroid issues, amiodarone can also lead to other side effects such as pulmonary fibrosis and photosensitivity reactions. It is important to monitor thyroid function tests regularly when taking amiodarone and to report any symptoms of thyroid dysfunction to a healthcare provider.
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This question is part of the following fields:
- Cardiovascular Health
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Question 30
Incorrect
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During his annual health review, a 67-year-old man with type 2 diabetes, hypercholesterolaemia, and hypertension is taking metformin, gliclazide, atorvastatin, and ramipril. His recent test results show a Na+ level of 139 mmol/L (135 - 145), K+ level of 4.1 mmol/L (3.5 - 5.0), creatinine level of 90 µmol/L (55 - 120), estimated GFR of 80 mL/min/1.73m² (>90), HbA1c level of 59 mmol/mol (<42), and urine albumin: creatinine ratio of <3 mg/mmol (<3). What is the recommended target clinic blood pressure (in mmHg)?
Your Answer:
Correct Answer:
Explanation:For patients with type 2 diabetes who do not have chronic kidney disease, the recommended blood pressure targets are the same as for patients without diabetes. This means a clinic reading of less than 140/90 mmHg and an ambulatory or home blood pressure reading of less than 135/85 mmHg if the patient is under 80 years old. It’s important to note that even if the patient’s estimated glomerular filtration rate (eGFR) is below 90, this doesn’t necessarily mean they have CKD unless there is also evidence of microalbuminuria.
NICE has updated its guidance on the management of type 2 diabetes mellitus (T2DM) in 2022 to reflect advances in drug therapy and improved evidence regarding newer therapies such as SGLT-2 inhibitors. For the average patient taking metformin for T2DM, lifestyle changes and titrating up metformin to aim for a HbA1c of 48 mmol/mol (6.5%) is recommended. A second drug should only be added if the HbA1c rises to 58 mmol/mol (7.5%). Dietary advice includes encouraging high fiber, low glycemic index sources of carbohydrates, controlling intake of saturated fats and trans fatty acids, and initial target weight loss of 5-10% in overweight individuals.
Individual HbA1c targets should be agreed upon with patients to encourage motivation, and HbA1c should be checked every 3-6 months until stable, then 6 monthly. Targets should be relaxed on a case-by-case basis, with particular consideration for older or frail adults with type 2 diabetes. Metformin remains the first-line drug of choice, and SGLT-2 inhibitors should be given in addition to metformin if the patient has a high risk of developing cardiovascular disease (CVD), established CVD, or chronic heart failure. If metformin is contraindicated, SGLT-2 monotherapy or a DPP-4 inhibitor, pioglitazone, or sulfonylurea may be used.
Further drug therapy options depend on individual clinical circumstances and patient preference. Dual therapy options include adding a DPP-4 inhibitor, pioglitazone, sulfonylurea, or SGLT-2 inhibitor (if NICE criteria are met). If a patient doesn’t achieve control on dual therapy, triple therapy options include adding a sulfonylurea or GLP-1 mimetic. GLP-1 mimetics should only be added to insulin under specialist care. Blood pressure targets are the same as for patients without type 2 diabetes, and ACE inhibitors or ARBs are first-line for hypertension. Antiplatelets should not be offered unless a patient has existing cardiovascular disease, and only patients with a 10-year cardiovascular risk > 10% should be offered a statin.
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This question is part of the following fields:
- Cardiovascular Health
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