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  • Question 1 - A 62-year-old man has recently started taking a new medication for his hypertension....

    Correct

    • A 62-year-old man has recently started taking a new medication for his hypertension. He has noticed swelling in his ankles and wonders if it could be a side effect of the medication. Which drug is most likely responsible for his symptoms?

      Your Answer: Amlodipine

      Explanation:

      Understanding Amlodipine: A Calcium-Channel Blocker and its Side-Effects

      Amlodipine is a medication that belongs to the class of calcium-channel blockers. It works by inhibiting the inward displacement of calcium ions through the slow channels of active cell membranes. The primary effect of amlodipine is to relax vascular smooth muscle and dilate peripheral and coronary arteries. However, this medication is also associated with some side-effects due to its vasodilatory properties.

      Common side-effects of amlodipine include flushing and headache, which usually subside after a few days. Another common side-effect is ankle swelling, which only partially responds to diuretics. In some cases, ankle swelling may be severe enough to warrant discontinuation of the drug. On the other hand, oedema is uncommon with losartan and not reported for any of the other options.

      If you experience oedema due to calcium-channel blockers, it is important to manage it properly. Please refer to the external links for more information on how to manage this side-effect.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 2 - 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: < 130/80 mmHg

      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 3 - A 55-year-old man presents to his General Practitioner to discuss the uptitration of...

    Correct

    • A 55-year-old man presents to his General Practitioner to discuss the uptitration of his medication as advised by cardiology. He suffered an anterior myocardial infarction (MI) four weeks ago. His history reveals that he is a smoker (20 per day for 30 years) and works in a sedentary office job, where he often works long days and eats ready meals to save time with food preparation.
      On examination, his heart rate is 62 bpm and his blood pressure is 126/74 mmHg, body mass index (BMI) is 31. His bisoprolol is increased to 5 mg and ramipril to 7.5 mg.
      Which of the following is the single non-pharmacological intervention that will be most helpful in reducing his risk of a future ischaemic event?

      Your Answer: Stopping smoking

      Explanation:

      Reducing Cardiovascular Risk: Lifestyle Changes to Consider

      Cardiovascular disease (CVD) is a leading cause of death worldwide, but many of the risk factors are modifiable through lifestyle changes. The three most important modifiable and causal risk factors are smoking, hypertension, and abnormal lipids. While hypertension and abnormal lipids may require medication to make significant changes, smoking cessation is the single most important non-pharmacological, modifiable risk factor in reducing cardiovascular risk.

      In addition to quitting smoking, there are other lifestyle changes that can help reduce cardiovascular risk. A cardioprotective diet should limit total fat intake to 30% or less of total energy intake, with saturated fat intake below 7%. Low-carbohydrate dietary intake is also thought to be important in cardiovascular disease prevention.

      Regular exercise is also important, with 150 minutes or more per week of moderate-intensity aerobic activity and muscle-strengthening activities on at least two days a week recommended. While exercise is beneficial, stopping smoking remains the most effective lifestyle change for reducing cardiovascular risk.

      Salt restriction can also help reduce risk, with a recommended intake of less than 6 g per day. Patients should be advised to avoid adding salt to their meals and minimize processed foods.

      Finally, weight reduction should be advised to decrease future cardiovascular risk, with a goal of achieving a normal BMI. Obese patients should also be assessed for sleep apnea. By making these lifestyle changes, individuals can significantly reduce their risk of developing cardiovascular disease.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 4 - You assess a 68-year-old man with a history of angina and heart failure....

    Incorrect

    • You assess a 68-year-old man with a history of angina and heart failure. He is currently taking aspirin, simvastatin, bisoprolol, glyceryl trinitrate, ramipril, and furosemide, but he continues to experience frequent angina attacks during physical activity. You decide to introduce a calcium channel blocker. Which of the following would be the most suitable to add?

      Your Answer:

      Correct Answer: Felodipine

      Explanation:

      When beta-blockers fail to control angina, it is recommended to supplement with a dihydropyridine calcium channel blocker that has a longer duration of action.

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

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

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 5 - A 70-year-old man visits a neurovascular clinic for a check-up. He had a...

    Incorrect

    • A 70-year-old man visits a neurovascular clinic for a check-up. He had a stroke caused by a blood clot 3 weeks ago but has been recovering well. However, the patient had to discontinue taking clopidogrel 75 mg due to severe abdominal discomfort and diarrhea after switching from aspirin 300 mg daily. Since then, the symptoms have subsided.

      What would be the best medication(s) to recommend for preventing another stroke in this case?

      Your Answer:

      Correct Answer: Aspirin 75 mg plus modified release dipyridamole

      Explanation:

      When clopidogrel cannot be used, the recommended treatment for secondary stroke prevention is a combination of aspirin 75 mg and modified-release dipyridamole. Studies have shown that this combination is more effective than taking aspirin or modified-release dipyridamole alone. Ticagrelor is not currently recommended by NICE for this purpose, and prasugrel is contraindicated due to the risk of bleeding. Oral anticoagulants like warfarin are generally not used for secondary stroke prevention, with antiplatelets being the preferred treatment.

      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 6 - Which beta blocker has been approved for treating heart failure? ...

    Incorrect

    • Which beta blocker has been approved for treating heart failure?

      Your Answer:

      Correct Answer: Acebutolol

      Explanation:

      Heart Failure Treatment Options

      According to the 2010 update by the National Institute for Health and Care Excellence (NICE), there are several medications that are indicated for the treatment of heart failure. These medications include bisoprolol, metoprolol succinate, carvedilol, and nebivolol. These drugs are commonly used to manage heart failure symptoms and improve overall heart function. It is important to consult with a healthcare provider to determine the best treatment plan for each individual case of heart failure. With proper medication management, individuals with heart failure can experience improved quality of life and better outcomes.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 7 - A 55-year-old carpenter comes to see you in surgery following an MI three...

    Incorrect

    • A 55-year-old carpenter comes to see you in surgery following an MI three months previously.

      He has made a full recovery but wants to ask about his diet.

      Which one of the following foods should he avoid?

      Your Answer:

      Correct Answer: Pork

      Explanation:

      Tips for a Heart-Healthy Diet after a Heart Attack

      Following a heart attack, it is important to adopt a healthier overall diet to reduce the risk of future heart problems. Unhealthy diets have been attributed to up to 30% of all deaths from coronary heart disease (CHD). While reducing fat intake is important, exercise also plays a crucial role in maintaining heart health.

      Including canned and frozen fruits and vegetables in your diet is just as beneficial as fresh produce. A Mediterranean diet, which includes many protective elements for CHD, is recommended. Replacing butter with olive oil and mono-unsaturated margarine, such as those made from rape-seed or olive oil, is a healthier option. Organic butter is not any better for heart health than non-organic butter.

      To reduce cholesterol intake, it is recommended to eat less red meat and replace it with poultry. Margarine containing sitostanol ester may also help reduce cholesterol intake. Adding plant sterol to margarine has been shown to reduce serum low-density lipoprotein cholesterol. Eating more fish, including oily fish, at least once a week is also recommended.

      Switching to whole-grain bread instead of white bread and eating more root vegetables and green vegetables is also beneficial. Lastly, it is important to eat fruit every day. By following these tips, you can maintain a heart-healthy diet and reduce the risk of future heart problems.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 8 - A 50-year-old woman has a mid-systolic ejection murmur in the third left intercostals...

    Incorrect

    • A 50-year-old woman has a mid-systolic ejection murmur in the third left intercostals space. It radiates into the left arm and shoulder.
      Select from the list the single associated symptom that this woman is most likely to have.

      Your Answer:

      Correct Answer: Angina

      Explanation:

      Understanding Symptoms of Aortic Stenosis

      Aortic stenosis is a condition where the aortic valve becomes narrowed, leading to restricted blood flow from the heart. One of the most common symptoms of aortic stenosis is a murmur heard in the aortic area. This is often due to calcification of the valve. However, symptoms usually only appear when the stenosis becomes severe.

      Patients with aortic stenosis may experience dyspnea on exertion, which is difficulty breathing during physical activity. More concerning symptoms include angina, syncope, or symptoms of heart failure. Angina is caused by left ventricular hypertrophy, while syncope is thought to be due to a failure to increase cardiac output during times of peripheral vasodilation and subsequent hypotension. It’s important to note that drugs that cause peripheral vasodilation, such as nitrates or ACE inhibitors, can increase the risk of syncope.

      Dysphagia is a rare complication of left atrial hypertrophy due to mitral valve disease. Palpitations and transient ischemic attacks are not symptoms that are typically associated with aortic stenosis. The most common source of emboli with transient ischemic attacks is the carotids. Vertigo is not caused by aortic stenosis.

      In summary, understanding the symptoms of aortic stenosis is crucial for early detection and treatment. If you experience any concerning symptoms, it’s important to speak with your healthcare provider.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 9 - You receive a call from a nursing home about a 90-year-old male resident....

    Incorrect

    • You receive a call from a nursing home about a 90-year-old male resident. The staff are worried about his increasing unsteadiness on his feet in the past few months, which has led to several near-falls. They are also concerned that his DOAC medication puts him at risk of a bleed if he falls and hits his head.

      His current medications include amlodipine, ramipril, edoxaban, and alendronic acid.

      What steps should be taken in this situation?

      Your Answer:

      Correct Answer: Calculate her ORBIT score

      Explanation:

      It is not enough to withhold anticoagulation solely based on the risk of falls or old age. To determine the risk of stroke or bleeding in atrial fibrillation, objective measures such as the CHA2DS2-VASc and ORBIT scores should be used. The ORBIT score, rather than HAS-BLED, is now recommended by NICE for assessing bleeding risk. A history of falls doesn’t factor into the ORBIT score, but age does. Limiting the patient’s mobility by suggesting she only mobilizes with staff is impractical. There is no rationale for switching the edoxaban to an antiplatelet agent, as antiplatelets are not typically used in atrial fibrillation management unless there is a specific indication. Stopping edoxaban without calculating the appropriate scores could leave the patient at a high risk of stroke.

      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 10 - Which of the following is the least acknowledged in individuals who are prescribed...

    Incorrect

    • Which of the following is the least acknowledged in individuals who are prescribed amiodarone medication?

      Your Answer:

      Correct Answer: Gynaecomastia

      Explanation:

      Gynaecomastia can be caused by drugs such as spironolactone, which is the most frequent cause, as well as cimetidine and digoxin.

      Adverse Effects and Drug Interactions of Amiodarone

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

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

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 11 - A 55-year-old woman who has previously had breast cancer visits her nearby GP...

    Incorrect

    • A 55-year-old woman who has previously had breast cancer visits her nearby GP clinic complaining of swelling in her left calf for the past two days. Which scoring system should be utilized to evaluate her likelihood of having a deep vein thrombosis (DVT)?

      Your Answer:

      Correct Answer: Wells score

      Explanation:

      Deep vein thrombosis (DVT) is a serious condition that requires prompt diagnosis and management. The National Institute for Health and Care Excellence (NICE) updated their guidelines in 2020, recommending the use of direct oral anticoagulants (DOACs) as first-line treatment for most people with VTE, including as interim anticoagulants before a definite diagnosis is made. They also recommend the use of DOACs in patients with active cancer, as opposed to low-molecular weight heparin as was previously recommended. Routine cancer screening is no longer recommended following a VTE diagnosis.

      If a patient is suspected of having a DVT, a two-level DVT Wells score should be performed to assess the likelihood of the condition. If a DVT is ‘likely’ (2 points or more), a proximal leg vein ultrasound scan should be carried out within 4 hours. If the result is positive, then a diagnosis of DVT is made and anticoagulant treatment should start. If the result is negative, a D-dimer test should be arranged. If a proximal leg vein ultrasound scan cannot be carried out within 4 hours, a D-dimer test should be performed and interim therapeutic anticoagulation administered whilst waiting for the proximal leg vein ultrasound scan (which should be performed within 24 hours).

      The cornerstone of VTE management is anticoagulant therapy. The big change in the 2020 guidelines was the increased use of DOACs. Apixaban or rivaroxaban (both DOACs) should be offered first-line following the diagnosis of a DVT. Instead of using low-molecular weight heparin (LMWH) until the diagnosis is confirmed, NICE now advocate using a DOAC once a diagnosis is suspected, with this continued if the diagnosis is confirmed. If neither apixaban or rivaroxaban are suitable, then either LMWH followed by dabigatran or edoxaban OR LMWH followed by a vitamin K antagonist (VKA, i.e. warfarin) can be used.

      All patients should have anticoagulation for at least 3 months. Continuing anticoagulation after this period is partly determined by whether the VTE was provoked or unprovoked. If the VTE was provoked, the treatment is typically stopped after the initial 3 months (3 to 6 months for people with active cancer). If the VTE was

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 12 - A 65-year-old man comes to the clinic with a diastolic murmur that is...

    Incorrect

    • A 65-year-old man comes to the clinic with a diastolic murmur that is most audible at the left sternal edge. The apex beat is also displaced outwards. What condition is commonly associated with these symptoms?

      Your Answer:

      Correct Answer: Aortic regurgitation

      Explanation:

      Characteristics of Aortic Regurgitation

      Aortic regurgitation is a heart condition characterized by the backflow of blood from the aorta into the left ventricle during diastole. One of the key features of this condition is a blowing high pitched early diastolic murmur that can be heard immediately after A2. This murmur is loudest at the left third and fourth intercostal spaces.

      In addition to the murmur, aortic regurgitation can also cause displacement of the apex beat. This is due to the dilatation of the left ventricle, which occurs as a result of the increased volume of blood that flows back into the ventricle during diastole. Despite this dilatation, there is relatively little hypertrophy of the left ventricle.

      Overall, the combination of a high pitched early diastolic murmur and displacement of the apex beat can be strong indicators of aortic regurgitation.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 13 - An 80-year-old man comes in for a medication review. He has a history...

    Incorrect

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

      Your Answer:

      Correct Answer: Modified-release verapamil

      Explanation:

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

      Prescribing Guidance for Healthcare Professionals

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

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

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 14 - A 70-year-old woman presented with an ulcer over the left ankle, which had...

    Incorrect

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

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

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

      Your Answer:

      Correct Answer: Bilateral lower limb arteriogram

      Explanation:

      Venous Ulceration and Arterial Disease

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

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

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 15 - A 60-year-old man meets the criteria for initiating statin therapy for CVD prevention....

    Incorrect

    • A 60-year-old man meets the criteria for initiating statin therapy for CVD prevention. He reports a history of persistent unexplained generalised muscle pains and so a creatine kinase (CK) level is checked on a blood test prior to starting treatment.

      The CK result comes back and it is four times the upper limit of normal.

      What is the most appropriate management approach in this instance?

      Your Answer:

      Correct Answer: Statin therapy should not be started and a fibrate should be prescribed instead

      Explanation:

      Statin Therapy and Creatine Kinase Levels

      Prior to offering a statin, it is recommended to check creatine kinase (CK) levels in individuals with persistent generalised unexplained muscle pain, according to NICE guidelines. If CK levels are more than 5 times the upper limit of normal, statin therapy should not be started. The CK level should be rechecked after 7 days, and if it remains elevated to more than 5 times the upper limit of normal, a statin should not be initiated. However, if CK levels are elevated but less than 5 times the upper limit of normal, statin treatment can be initiated, but a lower dose is recommended. It is important to monitor CK levels in patients receiving statin therapy to ensure that muscle damage is not occurring.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 16 - A 54-year-old man has scheduled a meeting to discuss his struggles with poor...

    Incorrect

    • A 54-year-old man has scheduled a meeting to discuss his struggles with poor concentration and feeling sleepy while working. He works as a truck driver and frequently has to operate heavy machinery. His spouse has noticed that he experiences brief pauses in breathing while sleeping at night and occasionally makes choking sounds.

      The patient is currently receiving treatment for hypertension and benign prostatic hyperplasia. His Epworth sleepiness scale score is 16.

      Considering his condition, what is the best course of action for the patient to take regarding operating heavy machinery?

      Your Answer:

      Correct Answer: He is required to inform the DVLA and stop driving

      Explanation:

      If a person has mild, moderate, or severe obstructive sleep apnoea (OSA) that causes excessive daytime sleepiness, they must inform the Driver Vehicle and Licensing Agency (DVLA). Excessive sleepiness refers to sleepiness that can negatively impact driving. The severity of OSA is determined by the number of apnoea/hypopnoea episodes per hour (apnoea-hypopnoea index [AHI]). Mild OSA is defined as an AHI of 5-14 per hour, moderate OSA is an AHI of 15-30 per hour, and severe OSA is an AHI of more than 30 per hour. If a person is diagnosed with OSA and experiences enough sleepiness to impair driving, they must inform the DVLA and stop driving. In this case, there is no need to retake a driving assessment, and the GP will not inform the DVLA initially. However, if the patient fails to inform the DVLA after multiple reminders and being informed that the GP may break confidentiality, the GP will inform the DVLA. If a person is being investigated for or has a diagnosis of OSA but doesn’t experience daytime sleepiness severe enough to impair driving, they do not need to inform the DVLA or stop driving. If a person is successfully using continuous positive airway pressure (CPAP) or an intra-oral device and their symptoms are controlled to the point where they no longer impair driving, they should inform the DVLA but do not need to stop driving.

      Understanding Obstructive Sleep Apnoea/Hypopnoea Syndrome

      Obstructive sleep apnoea/hypopnoea syndrome (OSAHS) is a condition that causes interrupted breathing during sleep due to a blockage in the airway. This can lead to a range of health problems, including daytime somnolence, respiratory acidosis, and hypertension. There are several predisposing factors for OSAHS, including obesity, macroglossia, large tonsils, and Marfan’s syndrome. Partners of those with OSAHS often complain of excessive snoring and periods of apnoea.

      To assess sleepiness, patients may complete the Epworth Sleepiness Scale questionnaire, and undergo the Multiple Sleep Latency Test (MSLT) to measure the time it takes to fall asleep in a dark room. Diagnostic tests for OSAHS include sleep studies (polysomnography), which measure a range of physiological factors such as EEG, respiratory airflow, thoraco-abdominal movement, snoring, and pulse oximetry.

      Management of OSAHS includes weight loss and the use of continuous positive airway pressure (CPAP) as a first-line treatment for moderate or severe cases. Intra-oral devices, such as mandibular advancement, may be used if CPAP is not tolerated or for patients with mild OSAHS without daytime sleepiness. It is important to inform the DVLA if OSAHS is causing excessive daytime sleepiness. While there is limited evidence to support the use of pharmacological agents, they may be considered in certain cases.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 17 - A 50-year-old male is being reviewed after being admitted six weeks ago with...

    Incorrect

    • A 50-year-old male is being reviewed after being admitted six weeks ago with an inferior myocardial infarction (MI) and treated with thrombolysis. He has been prescribed atenolol 50 mg daily, aspirin, and rosuvastatin 10 mg daily upon discharge. He has quit smoking after his MI and is now asking which foods he should avoid.

      Your Answer:

      Correct Answer: Kippers

      Explanation:

      Diet Recommendations Following a Heart Attack

      Following a heart attack, it is important for patients to make dietary changes to reduce the risk of another cardiac event. One of the key recommendations is to avoid foods high in saturated fat, such as cheese, milk, and fried foods. Instead, patients should switch to a diet rich in high-fiber, starch-based foods, and aim to consume five portions of fresh fruits and vegetables daily, as well as oily fish.

      However, it is important to note that NICE guidance on Acute Coronary Syndromes (NG185) advises against the use of omega-3 capsules and supplements to prevent another heart attack. While oily fish is still recommended as a source of omega-3, patients should not rely on supplements as a substitute for a healthy diet. By making these dietary changes, patients can improve their heart health and reduce the risk of future cardiac events.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 18 - A 53-year-old female visits her GP after experiencing a brief episode of right-sided...

    Incorrect

    • A 53-year-old female visits her GP after experiencing a brief episode of right-sided weakness lasting 10-15 minutes. During examination, the GP discovers that the patient has atrial fibrillation. If the patient continues to have chronic atrial fibrillation, what is the most appropriate type of anticoagulation to use?

      Your Answer:

      Correct Answer: Direct oral anticoagulant

      Explanation:

      When it comes to reducing the risk of stroke in patients with AF, DOACs should be the first option. In the case of this patient, her CHA2DS2-VASc score is 3, with 2 points for the transient ischaemic attack and 1 point for being female. Therefore, it is recommended that she be given anticoagulation treatment with DOACs, which are now preferred over warfarin.

      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 19 - A 72-year-old man presents with palpitations and feeling dizzy. An ECG reveals atrial...

    Incorrect

    • A 72-year-old man presents with palpitations and feeling dizzy. An ECG reveals atrial fibrillation with a heart rate of 130 beats per minute. His blood pressure is within normal limits and there are no other notable findings upon examination of his cardiorespiratory system. He has a medical history of controlled asthma (treated with salbutamol and beclomethasone) and depression (managed with citalopram). He has been experiencing these symptoms for approximately three days. What is the most suitable medication for controlling his heart rate?

      Your Answer:

      Correct Answer: Diltiazem

      Explanation:

      Prescribing a beta-blocker is not recommended due to her asthma history, which is a contraindication. Instead, NICE suggests using a calcium channel blocker that limits the heart rate. Additionally, it is important to consider antithrombotic therapy.

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

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 20 - A 67-year-old lady with mitral valve disease and atrial fibrillation is on warfarin...

    Incorrect

    • A 67-year-old lady with mitral valve disease and atrial fibrillation is on warfarin therapy. Recently, her INR levels have decreased, leading to an increase in the warfarin dosage. What new treatments could be responsible for this change?

      Your Answer:

      Correct Answer: St John's wort

      Explanation:

      Drug Interactions with Warfarin

      Drugs that are metabolized in the liver can induce hepatic microsomal enzymes, which can affect the metabolism of other drugs. In the case of warfarin, an anticoagulant medication, certain drugs can either enhance or reduce its effectiveness.

      St. John’s wort is an enzyme inducer and can increase the metabolism of warfarin, making it less effective. On the other hand, allopurinol can interact with warfarin to enhance its anticoagulant effect. Similarly, amiodarone inhibits the metabolism of coumarins, which can lead to an enhanced anticoagulant effect.

      Clarithromycin, a drug that inhibits CYP3A isozyme, can enhance the anticoagulant effect of coumarins, including warfarin. This is because warfarin is metabolized by the same CYP3A isozyme as clarithromycin. Finally, sertraline may also interact with warfarin to enhance its anticoagulant effect.

      In summary, it is important to be aware of potential drug interactions when taking warfarin, as they can either enhance or reduce its effectiveness. Patients should always inform their healthcare provider of all medications they are taking to avoid any potential adverse effects.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 21 - A 68-year-old man with lung cancer is diagnosed with deep vein thrombosis. He...

    Incorrect

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

      Your Answer:

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

      Explanation:

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

      Deep vein thrombosis (DVT) is a serious condition that requires prompt diagnosis and management. The National Institute for Health and Care Excellence (NICE) updated their guidelines in 2020, recommending the use of direct oral anticoagulants (DOACs) as first-line treatment for most people with VTE, including as interim anticoagulants before a definite diagnosis is made. They also recommend the use of DOACs in patients with active cancer, as opposed to low-molecular weight heparin as was previously recommended. Routine cancer screening is no longer recommended following a VTE diagnosis.

      If a patient is suspected of having a DVT, a two-level DVT Wells score should be performed to assess the likelihood of the condition. If a DVT is ‘likely’ (2 points or more), a proximal leg vein ultrasound scan should be carried out within 4 hours. If the result is positive, then a diagnosis of DVT is made and anticoagulant treatment should start. If the result is negative, a D-dimer test should be arranged. If a proximal leg vein ultrasound scan cannot be carried out within 4 hours, a D-dimer test should be performed and interim therapeutic anticoagulation administered whilst waiting for the proximal leg vein ultrasound scan (which should be performed within 24 hours).

      The cornerstone of VTE management is anticoagulant therapy. The big change in the 2020 guidelines was the increased use of DOACs. Apixaban or rivaroxaban (both DOACs) should be offered first-line following the diagnosis of a DVT. Instead of using low-molecular weight heparin (LMWH) until the diagnosis is confirmed, NICE now advocate using a DOAC once a diagnosis is suspected, with this continued if the diagnosis is confirmed. If neither apixaban or rivaroxaban are suitable, then either LMWH followed by dabigatran or edoxaban OR LMWH followed by a vitamin K antagonist (VKA, i.e. warfarin) can be used.

      All patients should have anticoagulation for at least 3 months. Continuing anticoagulation after this period is partly determined by whether the VTE was provoked or unprovoked. If the VTE was provoked, the treatment is typically stopped after the initial 3 months (3 to 6 months for people with active cancer). If the VTE was

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 22 - What is the typical target INR for a patient with a mechanical aortic...

    Incorrect

    • What is the typical target INR for a patient with a mechanical aortic valve?

      Your Answer:

      Correct Answer: 3.5

      Explanation:

      The recommended target INR for mechanical valves is 3.0 for aortic valves and 3.5 for mitral valves.

      Prosthetic Heart Valves: Options and Considerations

      Prosthetic heart valves are commonly used to replace damaged or diseased valves in the heart. The two main options for replacement are biological (bioprosthetic) or mechanical valves. Bioprosthetic valves are usually derived from bovine or porcine sources and are preferred for older patients. However, they have a major disadvantage of structural deterioration and calcification over time. On the other hand, mechanical valves have a low failure rate but require long-term anticoagulation due to the increased risk of thrombosis. Warfarin is still the preferred anticoagulant for patients with mechanical heart valves, and the target INR varies depending on the valve location. Aspirin is only given in addition if there is an additional indication, such as ischaemic heart disease.

      It is important to consider the patient’s age, medical history, and lifestyle when choosing a prosthetic heart valve. While bioprosthetic valves may not require long-term anticoagulation, they may need to be replaced sooner than mechanical valves. Mechanical valves, on the other hand, may require lifelong anticoagulation, which can be challenging for some patients. Additionally, following the 2008 NICE guidelines, antibiotics are no longer recommended for common procedures such as dental work for prophylaxis of endocarditis. Therefore, it is crucial to weigh the benefits and risks of each option and make an informed decision with the patient.

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      • Cardiovascular Health
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  • Question 23 - You see a 65-year-old gentleman who was diagnosed with heart failure and an...

    Incorrect

    • You see a 65-year-old gentleman who was diagnosed with heart failure and an ejection fraction of 35%. He is currently on the maximum tolerated dose of an ACE-I and beta blocker. He reports to still be symptomatic from his heart failure.

      What would be the next appropriate step in his management to improve his prognosis?

      Your Answer:

      Correct Answer: Refer to a heart failure specialist as no other drugs should be prescribed in primary care

      Explanation:

      MRA Treatment for Heart Failure Patients

      According to NICE guidelines, patients with heart failure and a reduced ejection fraction who continue to experience symptoms of heart failure should be offered an MRA such as spironolactone or eplerenone. Previously, only a heart failure specialist could initiate these treatments. However, now it is recommended that all healthcare professionals involved in the care of heart failure patients should consider offering these treatments to improve symptoms and reduce the risk of hospitalization. This guideline update aims to ensure that more patients have access to effective treatments for heart failure.

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      • Cardiovascular Health
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  • Question 24 - A 26-year-old female comes to her GP complaining of feeling tired and experiencing...

    Incorrect

    • A 26-year-old female comes to her GP complaining of feeling tired and experiencing episodes of dizziness. During the examination, the GP observes an absent pulse in the patient's left radial artery. The following blood test results are obtained:

      - Sodium (Na+): 136 mmol/l
      - Potassium (K+): 4.1 mmol/l
      - Urea: 2.3 mmol/l
      - Creatinine: 77 µmol/l
      - Erythrocyte sedimentation rate (ESR): 66 mm/hr

      Based on these findings, what is the most likely diagnosis?

      Your Answer:

      Correct Answer: Takayasu's arteritis

      Explanation:

      Takayasu’s arteritis is a type of vasculitis that affects the large blood vessels, often leading to blockages in the aorta. This condition is more commonly seen in young women and Asian individuals. Symptoms may include malaise, headaches, unequal blood pressure in the arms, carotid bruits, absent or weak peripheral pulses, and claudication in the limbs during physical activity. Aortic regurgitation may also occur in around 20% of cases. Renal artery stenosis is a common association with this condition. To diagnose Takayasu’s arteritis, vascular imaging of the arterial tree is necessary, which can be done through magnetic resonance angiography or CT angiography. Treatment typically involves the use of steroids.

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      • Cardiovascular Health
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  • Question 25 - A 35-year-old woman of African origin comes in for a routine health check....

    Incorrect

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

      Your Answer:

      Correct Answer: Start an ACE inhibitor

      Explanation:

      Treatment Recommendations for Hypertension

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

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      • Cardiovascular Health
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  • Question 26 - A 35-year-old man is referred by the practice nurse following a routine health...

    Incorrect

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

      Your Answer:

      Correct Answer: Statin

      Explanation:

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

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      • Cardiovascular Health
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  • Question 27 - A 67-year-old man presents for follow-up. He has a medical history of small...

    Incorrect

    • A 67-year-old man presents for follow-up. He has a medical history of small cell lung cancer and ischemic heart disease. His cancer was detected five months ago and he recently finished a round of chemotherapy. In terms of his heart health, he experienced a heart attack two years ago and underwent primary angioplasty with stent placement. He has not had any angina since then.

      Over the past week, he has been experiencing increasing shortness of breath, particularly at night, and has an occasional non-productive cough. He has also noticed that his wedding ring feels tight. Upon examination, his chest appears normal, but he does have distended neck veins and periorbital edema. What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Superior vena cava obstruction

      Explanation:

      Understanding Superior Vena Cava Obstruction

      Superior vena cava obstruction is a medical emergency that occurs when the superior vena cava, a large vein that carries blood from the upper body to the heart, is compressed. This condition is commonly associated with lung cancer, but it can also be caused by other malignancies, aortic aneurysm, mediastinal fibrosis, goitre, and SVC thrombosis. The most common symptom of SVC obstruction is dyspnoea, but patients may also experience swelling of the face, neck, and arms, headache, visual disturbance, and pulseless jugular venous distension.

      The management of SVC obstruction depends on the underlying cause and the patient’s individual circumstances. Endovascular stenting is often the preferred treatment to relieve symptoms, but certain malignancies may require radical chemotherapy or chemo-radiotherapy instead. Glucocorticoids may also be given, although the evidence supporting their use is weak. It is important to seek advice from an oncology team to determine the best course of action for each patient.

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      • Cardiovascular Health
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  • Question 28 - You are examining the results of an ambulatory blood pressure monitor (ABPM) for...

    Incorrect

    • You are examining the results of an ambulatory blood pressure monitor (ABPM) for a 65-year-old man with suspected hypertension. You have also arranged an ECG, blood tests and a urine dipstick, all of which have been normal. According to QRISK, his 10-year cardiovascular risk is 7%. The ABPM results reveal an average daytime reading of 148/94 mmHg. What is the best course of action?

      Your Answer:

      Correct Answer: Diagnose stage 1 hypertension and advise about lifestyle changes

      Explanation:

      This pertains to the utilization of statins for initial prevention, as opposed to the present NICE guidelines for hypertension.

      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 29 - A 56-year-old patient has recently been diagnosed with heart failure. Choose from the...

    Incorrect

    • A 56-year-old patient has recently been diagnosed with heart failure. Choose from the options the medical condition that would most likely prevent the use of ß-blockers in this patient.

      Your Answer:

      Correct Answer: Asthma

      Explanation:

      The Benefits and Considerations of β-Blockers in Heart Failure Patients

      β-blockers have been proven to provide significant benefits for patients with heart failure and should be offered to all eligible patients. It is recommended to start with the lowest possible dose and gradually increase it. While β-blockers can generally be safely administered to patients with COPD, caution should be exercised in patients with a history of asthma due to the risk of bronchospasm. However, cardioselective β-blockers such as atenolol, bisoprolol, metoprolol, nebivolol, and acebutolol may be used under specialist supervision. These medications are not cardiac specific and may still have an effect on airway resistance.

      In addition to heart failure, β-blockers can also be used for rate control in patients with atrial fibrillation and as a first-line treatment for angina. While they may worsen symptoms of peripheral vascular disease, this is not a complete contraindication to their use.

      Overall, β-blockers have proven to be a valuable treatment option for heart failure patients, but careful consideration should be given to individual patient factors before prescribing.

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      • Cardiovascular Health
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  • Question 30 - A 41-year-old man is worried about his risk of heart disease due to...

    Incorrect

    • A 41-year-old man is worried about his risk of heart disease due to his family history. His father passed away at the age of 45 from a heart attack. During his medical check-up, his lipid profile is as follows:

      HDL 1.4 mmol/l
      LDL 5.7 mmol/l
      Triglycerides 2.3 mmol/l
      Total cholesterol 8.2 mmol/l

      Upon clinical examination, the doctor notices tendon xanthomata around his ankles. What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Familial hypercholesterolaemia

      Explanation:

      Familial hypercholesterolaemia can be diagnosed when there are tendon xanthomata and elevated cholesterol levels present.

      Familial Hypercholesterolaemia: Causes, Diagnosis, and Management

      Familial hypercholesterolaemia (FH) is a genetic condition that affects approximately 1 in 500 people. It is an autosomal dominant disorder that results in high levels of LDL-cholesterol, which can lead to early cardiovascular disease if left untreated. FH is caused by mutations in the gene that encodes the LDL-receptor protein.

      To diagnose FH, NICE recommends suspecting it as a possible diagnosis in adults with a total cholesterol level greater than 7.5 mmol/l and/or a personal or family history of premature coronary heart disease. For children of affected parents, testing should be arranged by age 10 if one parent is affected and by age 5 if both parents are affected.

      The Simon Broome criteria are used for clinical diagnosis, which includes a total cholesterol level greater than 7.5 mmol/l and LDL-C greater than 4.9 mmol/l in adults or a total cholesterol level greater than 6.7 mmol/l and LDL-C greater than 4.0 mmol/l in children. Definite FH is diagnosed if there is tendon xanthoma in patients or first or second-degree relatives or DNA-based evidence of FH. Possible FH is diagnosed if there is a family history of myocardial infarction below age 50 years in second-degree relatives, below age 60 in first-degree relatives, or a family history of raised cholesterol levels.

      Management of FH involves referral to a specialist lipid clinic and the use of high-dose statins as first-line treatment. CVD risk estimation using standard tables is not appropriate in FH as they do not accurately reflect the risk of CVD. First-degree relatives have a 50% chance of having the disorder and should be offered screening, including children who should be screened by the age of 10 years if there is one affected parent. Statins should be discontinued in women 3 months before conception due to the risk of congenital defects.

    • This question is part of the following fields:

      • Cardiovascular Health
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SESSION STATS - PERFORMANCE PER SPECIALTY

Cardiovascular Health (2/3) 67%
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