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  • Question 1 - Sophie is a 82-year-old woman with type 2 diabetes and hypertension. She visits...

    Correct

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

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

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

      Explanation:

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

      A transient ischaemic attack (TIA) is a brief period of neurological deficit caused by a vascular issue, lasting less than an hour. The original definition of a TIA was based on time, but it is now recognized that even short periods of ischaemia can result in pathological changes to the brain. Therefore, a new ’tissue-based’ definition is now used. The clinical features of a TIA are similar to those of a stroke, but the symptoms resolve within an hour. Possible features include unilateral weakness or sensory loss, aphasia or dysarthria, ataxia, vertigo, or loss of balance, visual problems, sudden transient loss of vision in one eye (amaurosis fugax), diplopia, and homonymous hemianopia.

      NICE recommends immediate antithrombotic therapy, giving aspirin 300 mg immediately unless the patient has a bleeding disorder or is taking an anticoagulant. If aspirin is contraindicated, management should be discussed urgently with the specialist team. Specialist review is necessary if the patient has had more than one TIA or has a suspected cardioembolic source or severe carotid stenosis. Urgent assessment within 24 hours by a specialist stroke physician is required if the patient has had a suspected TIA in the last 7 days. Referral for specialist assessment should be made as soon as possible within 7 days if the patient has had a suspected TIA more than a week previously. The person should be advised not to drive until they have been seen by a specialist.

      Neuroimaging should be done on the same day as specialist assessment if possible. MRI is preferred to determine the territory of ischaemia or to detect haemorrhage or alternative pathologies. Carotid imaging is necessary as atherosclerosis in the carotid artery may be a source of emboli in some patients. All patients should have an urgent carotid doppler unless they are not a candidate for carotid endarterectomy.

      Antithrombotic therapy is recommended, with clopidogrel being the first-line treatment. Aspirin + dipyridamole should be given to patients who cannot tolerate clopidogrel. Carotid artery endarterectomy should only be considered if the patient has suffered a stroke or TIA in the carotid territory and is not severely disabled. It should only be recommended if carotid stenosis is greater

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 2 - A 72-year-old lady comes to her GP for a yearly check-up of her...

    Incorrect

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

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

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

      Your Answer:

      Correct Answer: Isosorbide mononitrate

      Explanation:

      First Line Treatments for Heart Failure

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

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 3 - A 55-year-old man has suffered an extensive anterior myocardial infarction (MI) but has...

    Incorrect

    • A 55-year-old man has suffered an extensive anterior myocardial infarction (MI) but has recovered well in the hospital. His pre-discharge echocardiogram shows him to have a reduced ejection fraction of 35%. He has no dyspnoea, residual chest pain or significant oedema.
      Which is the single correct combination of drugs that he should be taking on discharge from the hospital?

      Your Answer:

      Correct Answer: Aspirin, clopidogrel, bisoprolol, ramipril and a statin

      Explanation:

      Optimum Treatments for Post-Myocardial Infarction Patients

      After a myocardial infarction, it is crucial for patients to receive the appropriate medications to prevent further complications. The following are some of the optimum treatments for post-MI patients:

      1. Aspirin, clopidogrel, bisoprolol, ramipril, and a statin: Beta-blockers like bisoprolol are essential for patients with left ventricular dysfunction. ACE inhibitors like ramipril are also recommended for post-MI and asymptomatic left ventricular dysfunction. Aspirin, another antiplatelet drug, and a statin are also widely used.

      2. Aspirin, ticagrelor, losartan, and a statin: Ticagrelor can be used instead of clopidogrel for certain patients. Losartan, an angiotensin 2 receptor blocker, can replace an ACE inhibitor if the latter is not tolerated.

      3. Aspirin, bisoprolol, ramipril, amlodipine, and a statin: Amlodipine can be added for hypertensive control if needed. However, other calcium blockers can increase mortality in patients with poor left ventricular function post-MI.

      4. Aspirin, bisoprolol, ramipril, furosemide, and a statin: Furosemide is only added for the treatment of symptomatic congestive cardiac failure.

      5. Aspirin, isosorbide mononitrate, ramipril, and a statin: Isosorbide mononitrate may be used for symptomatic relief of angina symptoms but is not routinely prescribed after an MI. The absence of a beta-blocker and second antiplatelet also makes this choice suboptimal.

      In conclusion, post-MI patients should receive a combination of medications tailored to their individual needs to prevent further complications and improve their quality of life.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 4 - A 65-year-old lady presents with a brief history of sudden onset severe left...

    Incorrect

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

      Your Answer:

      Correct Answer: Sciatica

      Explanation:

      Acute Limb Ischaemia: Causes and Symptoms

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

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

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

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 5 - 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.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 6 - A 56-year-old man collapses after complaining of palpitations and is admitted to the...

    Incorrect

    • A 56-year-old man collapses after complaining of palpitations and is admitted to the Emergency Department (ED). He is found to be in ventricular tachycardia and is successfully cardioverted. Further investigations reveal an underlying long QT syndrome, and an implantable cardioverter-defibrillator (ICD) is inserted. The man works as an HGV driver. What advice should be given regarding his ability to drive HGV vehicles?

      Your Answer:

      Correct Answer: Permanent bar

      Explanation:

      Regardless of the circumstances, the loss of HGV licence is indicated by ICD.

      DVLA Guidelines for Cardiovascular Disorders and Driving

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

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

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

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 7 - A 65-year-old man with a history of type 2 diabetes, moderate aortic stenosis,...

    Incorrect

    • A 65-year-old man with a history of type 2 diabetes, moderate aortic stenosis, and stage 3b chronic kidney disease presents for hypertension management. His blood pressure in the clinic is 150/90 mmHg, and he has been recording an average of 155/84 mmHg for the past month. He has previously refused antihypertensive medication due to concerns about dizziness and falls. What is the appropriate initial antihypertensive to consider in this case?

      Your Answer:

      Correct Answer: Calcium channel blocker

      Explanation:

      Due to the patient’s moderate-severe aortic stenosis, ACE inhibitors are contraindicated and a calcium channel blocker should be prescribed as the first-line treatment for hypertension. Alpha-blockers may be considered later in the treatment algorithm if necessary, typically at step 4 of the guidelines when potassium levels are high. While ACE inhibitors are typically recommended for patients with type 2 diabetes to protect the kidneys, they should not be used in this patient due to their aortic stenosis. Beta-blockers are not the first-line treatment for hypertension and are better suited for heart failure and post-myocardial infarction. They may be considered later in the treatment algorithm if needed, typically at step 4 when potassium levels are high.

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

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

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

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

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 8 - A 57-year-old man visits his GP for a blood pressure check. He has...

    Incorrect

    • A 57-year-old man visits his GP for a blood pressure check. He has a medical history of hypothyroidism, asthma, and high cholesterol. He reports feeling well, and his QRISK score is calculated at 11%.

      The patient is currently taking levothyroxine, atorvastatin, lercanidipine, beclomethasone, and salbutamol. He has no known allergies.

      After taking three readings, his blood pressure averages at 146/92 mmHg.

      What is the most appropriate course of action?

      Your Answer:

      Correct Answer: Addition of losartan

      Explanation:

      The patient’s current therapy doesn’t affect the treatment decision, but an additional medication from either the ACE-inhibitor or angiotensin receptor blocker class is recommended to control their blood pressure. According to updated guidelines from 2019, a thiazide-like diuretic may also be used. As losartan is the only medication from these classes, it is the correct choice. Bisoprolol, doxazosin, and spironolactone are typically reserved for cases of resistant hypertension that do not respond to combinations of a calcium channel blocker, a thiazide-like diuretic, and an ACE-inhibitor or angiotensin receptor blocker. Since the patient is only on a single therapy, adding any of these options is not currently indicated. Choosing to make no changes to the medication is incorrect, as the patient’s blood pressure remains above the target range of 140/90 mmHg.

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

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

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

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

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

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 9 - A 75 year old man has come for a surgical consultation regarding an...

    Incorrect

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

      Your Answer:

      Correct Answer: Lifestyle advice

      Explanation:

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

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

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

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

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

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

    • This question is part of the following fields:

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

    Incorrect

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

      What is the most suitable course of action?

      Your Answer:

      Correct Answer: Measure ankle : brachial systolic pressure index

      Explanation:

      Understanding Intermittent Claudication: Diagnosis and Management

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

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

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

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

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

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 11 - The nurse practitioner approaches you with a query after the clinic. A 50-year-old...

    Incorrect

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

      Your Answer:

      Correct Answer: Clopidogrel

      Explanation:

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

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

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

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

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 12 - A 55-year-old man presents to the surgery with intermittent palpitations, occurring for approximately...

    Incorrect

    • A 55-year-old man presents to the surgery with intermittent palpitations, occurring for approximately 60 minutes every five to six days.

      Careful questioning reveals no clear precipitating factors, and he is otherwise an infrequent attender to the surgery. On examination, his BP is 140/80 mmHg, his pulse irregular at 100 bpm, but otherwise cardiovascular and respiratory examination is unremarkable.

      You arrange for an ECG the following day with the practice nurse, which is normal.

      What is the next most appropriate step?

      Your Answer:

      Correct Answer: Arrange an event recorder ECG

      Explanation:

      Recommended Investigation for Diagnosis of Heart Condition

      The recommended investigation for confirming the diagnosis of the heart condition in this scenario is an event recorder electrocardiogram (ECG). This is because symptomatic episodes are more than 24 hours apart, making a 24-hour ambulatory ECG less likely to confirm the diagnosis. While echocardiography may be useful in evaluating atrial fibrillation, a diagnosis must first be made.

      It is important to note that there is no indication of haemodynamic compromise in this scenario, so acute admission is not necessary. By conducting the appropriate investigation, healthcare professionals can accurately diagnose and treat the heart condition.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 13 - 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.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 14 - 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:

      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 15 - You are about to start a patient in their 70s on lisinopril for...

    Incorrect

    • You are about to start a patient in their 70s on lisinopril for hypertension. Which one of the following conditions is most likely to increase the risk of side-effects?

      Your Answer:

      Correct Answer: Aortic stenosis

      Explanation:

      ACE inhibitors pose a significant risk of profound hypotension in patients with aortic stenosis. However, the co-prescription of bendroflumethiazide, a weak diuretic, is commonly used and doesn’t increase the risk of hypotension as seen with high-dose loop diuretics such as furosemide 80 mg bd. Patients with chronic kidney disease stage 2, which is characterized by a glomerular filtration rate of > 60 mL/min/1.73 m², are unlikely to experience significant side effects.

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

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

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

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

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 16 - A patient with long-standing chronic obstructive pulmonary disease (COPD) who is in their...

    Incorrect

    • A patient with long-standing chronic obstructive pulmonary disease (COPD) who is in their 60s now presents with symptoms of right heart failure. Upon examination, they are in sinus rhythm but have peripheral edema, a raised JVP, and a loud pulmonary second heart sound. The diagnosis is cor pulmonale. What is the recommended treatment for right heart failure that develops as a result of lung disease?

      Your Answer:

      Correct Answer: Angiotensin converting enzyme inhibitor

      Explanation:

      Managing Oedema in Cor Pulmonale Patients

      Patients with oedema caused by cor pulmonale can be treated with diuretic therapy. However, according to NICE guidelines on Chronic obstructive pulmonary disease (NG115), ACE inhibitors, alpha blockers, and calcium channel blockers should not be used. Digoxin should only be prescribed if the patient also has atrial fibrillation.

      It is important to assess patients for long-term oxygen therapy to manage their condition effectively. For more information on managing oedema in cor pulmonale patients, please refer to the NICE guidelines on Chronic obstructive pulmonary disease (NG115).

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 17 - You assess a 62-year-old man who has been discharged after experiencing a ST-elevation...

    Incorrect

    • You assess a 62-year-old man who has been discharged after experiencing a ST-elevation myocardial infarction (MI) and receiving percutaneous coronary intervention. What is the appropriate timeframe for him to resume sexual activity after his MI?

      Your Answer:

      Correct Answer: 4 weeks

      Explanation:

      After a heart attack, it is safe to resume sexual activity after a period of 4 weeks.

      Myocardial infarction (MI) is a serious condition that requires proper management to prevent further complications. The National Institute for Health and Care Excellence (NICE) has provided guidelines for the secondary prevention of MI. Patients who have had an MI should be offered dual antiplatelet therapy, ACE inhibitors, beta-blockers, and statins. Lifestyle changes such as following a Mediterranean-style diet and engaging in regular exercise are also recommended. Sexual activity may resume after four weeks, and PDE5 inhibitors may be used after six months, but caution should be exercised in patients taking nitrates or nicorandil.

      Dual antiplatelet therapy is now the standard treatment for most patients who have had an acute coronary syndrome. Ticagrelor and prasugrel are now more commonly used as ADP-receptor inhibitors. The NICE Clinical Knowledge Summaries recommend adding ticagrelor to aspirin for medically managed patients and prasugrel or ticagrelor for those who have undergone percutaneous coronary intervention. The second antiplatelet should be stopped after 12 months, but this may be adjusted for patients at high risk of bleeding or further ischaemic events.

      For patients who have had an acute MI and have symptoms and/or signs of heart failure and left ventricular systolic dysfunction, treatment with an aldosterone antagonist such as eplerenone should be initiated within 3-14 days of the MI, preferably after ACE inhibitor therapy. Proper management and adherence to these guidelines can significantly reduce the risk of further complications and improve the patient’s quality of life.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 18 - A 32-year-old man presents with a fasting lipid profile that shows a triglyceride...

    Incorrect

    • A 32-year-old man presents with a fasting lipid profile that shows a triglyceride level of 22 mmol/L. He denies excessive alcohol consumption and all other blood tests, including HbA1c, renal function, liver function, and thyroid function, are within normal limits. There is no clear explanation for the elevated triglyceride level, and there are no prior lipid profiles available for comparison. The patient has no significant medical history and is not taking any medications. He reports no symptoms or feelings of illness.
      What is the most appropriate management strategy for this patient?

      Your Answer:

      Correct Answer: Refer routinely for specialist assessment

      Explanation:

      Management of Hypertriglyceridaemia

      Hypertriglyceridaemia is a condition that increases the risk of pancreatitis, making prompt management crucial. The National Institute for Health and Care Excellence (NICE) has provided specific guidance on how to manage this condition.

      If the triglyceride level is above 20 mmol/L and not due to alcohol excess or poor glycaemic control, urgent referral to a lipid clinic is necessary. For levels between 10 mmol/L and 20 mmol/L, a fasting sample should be repeated no sooner than 5 days and no longer than 2 weeks later. If the level remains above 10 mmol/L, secondary causes of hypertriglyceridaemia should be considered, and specialist advice should be sought.

      For those with a triglyceride level between 4.5 and 9.9 mmol/L, clinicians should consider that cardiovascular disease (CVD) risk may be underestimated using risk assessment tools such as QRISK. They should optimize the management of other CVD risk factors, and specialist advice should be sought if the non-HDL cholesterol level is above 7.5 mmol/L.

      In summary, the management of hypertriglyceridaemia requires careful consideration of the triglyceride level and other risk factors. Early referral to a lipid clinic and specialist advice can help prevent complications such as pancreatitis and reduce the risk of CVD.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 19 - A 55-year-old male with diabetes is diagnosed with hypertension.

    You discuss starting treatment and...

    Incorrect

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

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

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

      What blood test monitoring should next be performed?

      Your Answer:

      Correct Answer: Repeat renal function in 7-14 days

      Explanation:

      Renal Function Monitoring for ACE Inhibitor Treatment

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

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

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 20 - Your patient, who has been discharged after a non-ST elevation myocardial infarction, is...

    Incorrect

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

      Your Answer:

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

      Explanation:

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

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

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

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

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 21 - A 63-year-old man presents with a three-month history of palpitation. He reports feeling...

    Incorrect

    • A 63-year-old man presents with a three-month history of palpitation. He reports feeling his heart skip a beat regularly but denies any other symptoms such as dizziness, shortness of breath, chest pain, or fainting.

      Upon examination, his chest is clear and his oxygen saturation is 98%. Heart sounds are normal and there is no peripheral edema. His blood pressure is 126/64 mmHg and his ECG shows an irregularly irregular rhythm with no P waves and a heart rate of 82/min.

      What is the most appropriate next step in managing this patient?

      Your Answer:

      Correct Answer: Assessment using ORBIT bleeding risk tool and CHA2DS2-VASc tool

      Explanation:

      To determine the need for anticoagulation in patients with atrial fibrillation, it is necessary to conduct an assessment using both the CHA2DS2-VASc tool and the ORBIT bleeding risk tool. This applies to all patients with atrial fibrillation, according to current NICE CKS guidance. Therefore, the option to commence on apixaban and bisoprolol is not correct.

      The patient’s symptoms and ECG findings indicate atrial fibrillation, but there is no indication for a 24-hour ECG. Therefore, referral for a 24-hour ECG and commencing on apixaban and bisoprolol is not necessary.

      As there are no signs or symptoms of heart failure and no evidence of valvular heart disease on examination, referral for an echocardiogram and commencing on apixaban and bisoprolol is not the appropriate option.

      The patient is currently haemodynamically stable.

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

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

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

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 22 - You see a 70-year-old male smoker in clinic who describes symptoms of pain...

    Incorrect

    • You see a 70-year-old male smoker in clinic who describes symptoms of pain in his left leg which is exacerbated by exercise and relieved by rest.

      On examination his pulses are weak in the left leg compared to the right. Suspecting intermittent claudication you arrange leg Dopplers. These show an ABPI (ankle brachial pressure Index) of 0.84.

      What is the appropriate diagnosis for this man based on these findings?

      Your Answer:

      Correct Answer: Peripheral arterial disease

      Explanation:

      Understanding ABPI and its Interpretation

      The Ankle-Brachial Pressure Index (ABPI) is a ratio that compares the systolic pressure in the ankle to that in the arm. It is a non-invasive test that helps diagnose peripheral arterial disease (PAD), a condition that affects blood flow to the legs and feet.

      An ABPI of less than 0.9 indicates the presence of PAD, while an ABPI of less than 0.8 suggests a higher risk of developing ulcers. An ABPI of less than 0.5 indicates critical ischaemia, a severe form of PAD that can lead to tissue damage and even amputation.

      On the other hand, an ABPI of more than 1.5 is likely due to non-compressible vessels, which means that the arteries are too stiff to be accurately measured. In such cases, the ABPI cannot be relied upon to guide clinical decisions.

      In summary, the ABPI is a useful tool in diagnosing and assessing the severity of PAD. Healthcare professionals should interpret the results carefully and take appropriate action based on the patient’s individual circumstances.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 23 - Which of the following statements about warfarin is accurate? ...

    Incorrect

    • Which of the following statements about warfarin is accurate?

      Your Answer:

      Correct Answer: Warfarin can be used when breastfeeding

      Explanation:

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

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

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

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

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

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 24 - The use of beta-blockers in treating hypertension has decreased significantly over the last...

    Incorrect

    • The use of beta-blockers in treating hypertension has decreased significantly over the last half-decade. What are the primary factors contributing to this decline?

      Your Answer:

      Correct Answer: Less likely to prevent stroke + potential impairment of glucose tolerance

      Explanation:

      The ASCOT-BPLA study showcased this phenomenon.

      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 25 - A 67-year-old man presents for a medication review after being discharged from the...

    Incorrect

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

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

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

      Your Answer:

      Correct Answer: Felodipine

      Explanation:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 26 - A 50-year-old woman is visiting the clinic several months after experiencing a heart...

    Incorrect

    • A 50-year-old woman is visiting the clinic several months after experiencing a heart attack. She has been prescribed medications to lower her risk of cardiovascular disease and has made dietary changes to promote healthy living. However, she has recently reported experiencing muscle aches and pains and her CK levels are elevated. Which of the following foods or substances may have contributed to the increased risk of statin-related myotoxicity?

      Your Answer:

      Correct Answer: Cranberry juice

      Explanation:

      Drug Interactions with Fruit Juices and Supplements

      Grapefruit juice can significantly increase the serum concentrations of certain statins by reducing their first-pass metabolism in the small intestine through the inhibition of CYP3A4. Therefore, it is recommended to avoid consuming large amounts of grapefruit juice while taking atorvastatin or to adjust the dosage accordingly. CYP3A4 is a member of the cytochrome P450 system.

      On the other hand, while an interaction between cranberry juice and warfarin has been recognized, there have been no reported interactions with other drugs metabolized via the P450 system. Additionally, there have been no known interactions between statins, carrot juice, garlic, or omega-3 fish oils. However, it is important to note that according to NICE CG172, patients should no longer be advised to take omega-3 supplements to prevent another MI.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 27 - You are assessing a 65-year-old man who has presented with concerns about his...

    Incorrect

    • You are assessing a 65-year-old man who has presented with concerns about his varicose veins. He has noticed that they have become more noticeable over the past year, but he doesn't experience any pain.

      Upon examination, you observe bilateral prominent varicose veins on his lower legs. There are no accompanying skin changes or leg swelling. His distal pulses are normal, and his feet are warm to the touch.

      The patient has no significant medical history, and recent blood tests, including an HbA1c, are within normal limits.

      As per current NICE guidelines, what is the recommended course of action for managing this patient's varicose veins?

      Your Answer:

      Correct Answer: Arrange an ankle brachial pressure index (ABPI)

      Explanation:

      Before offering graduated compression stockings to a patient with varicose veins, it is important to arrange an ABPI to exclude arterial insufficiency. If the ABPI is between 0.8 and 1.3, compression stockings are generally safe to wear. Topical steroids are not effective in treating varicose veins and a referral to vascular is not necessary for uncomplicated cases in primary care. Duplex ultrasonography is usually arranged by the vascular team in secondary care.

      Understanding Varicose Veins

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

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

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

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 28 - A 70-year-old woman is prescribed amlodipine 5mg once daily for hypertension. She has...

    Incorrect

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

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

      Your Answer:

      Correct Answer:

      Explanation:

      The recommended blood pressure target for individuals under 80 years old during a clinic reading is 140/90 mmHg. However, the Quality and Outcomes Framework (QOF) indicator for GPs practicing in England specifies a slightly higher target of below 150/90 mmHg.

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

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

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

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

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

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 29 - A 68-year-old-man visits his General Practitioner complaining of syncope without any prodromal features....

    Incorrect

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

      Your Answer:

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

      Explanation:

      Understanding the Clinical Signs of Complete Heart Block

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

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

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

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

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

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

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

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      • Cardiovascular Health
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  • Question 30 - A 60-year-old man has recently been discharged from hospital with a new diagnosis...

    Incorrect

    • A 60-year-old man has recently been discharged from hospital with a new diagnosis of heart failure with reduced ejection fraction. His symptoms of breathlessness and ankle swelling have now resolved and he has been commenced on ramipril, bisoprolol and furosemide. He also has type 2 diabetes, for which he is already taking metformin and gliclazide. His renal function is normal and his serum potassium is 4.9 mmol/L.

      What ongoing care interventions should be included for this patient?

      Your Answer:

      Correct Answer: Annual influenza vaccination

      Explanation:

      An annual influenza vaccine should be offered as part of the comprehensive lifestyle approach to managing heart failure.

      Individuals diagnosed with heart failure with reduced ejection fraction should receive an annual influenza vaccine and a one-time pneumococcal vaccination.

      Typically, only those with asplenia, splenic dysfunction, or chronic kidney disease require pneumococcal revaccination every five years.

      Following a myocardial infarction, patients are typically advised to abstain from sexual activity for four weeks, rather than heart failure.

      While patients should limit their salt intake to no more than 6 g per day, they should not replace it with potassium-containing salt substitutes due to the risk of hyperkalemia when used concurrently with ACE inhibitors.

      For group 1 entitlement (cars, motorcycles), driving may continue as long as there are no symptoms that could distract the driver’s attention, and there is no need to notify the DVLA.

      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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