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Cardiovascular Health Flashcards

1
Q

You see an 82-year-old man in your morning surgery for a hypertension review. He is currently taking amlodipine.

What is the TARGET blood pressure for this patient? Select ONE option only.

A. Lower than 160/90 mmHg
B. Lower than 135/85 mmHg
C. Lower than 150/90 mmHg
D. Lower than 140/80 mmHg
E. Lower than 140/90 mmHg

A

Answer: C. Lower than 150/90 mmHg

Answer justification and feedback:
Blood pressure targets are currently:
• For people aged under 80 years: lower than 140/90 mmHg
• For people aged over 80 years: lower than 150/90 mmHg

Resource:
NICE. Hypertension in Adults: diagnosis and management. NG136. 2019 (updated 2022).
https://www.nice.org.uk/guidance/ng136

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2
Q

For a person with heart disease who has gained weight, has become very tired and feels the cold a lot.

Which is the SINGLE MOST likely causative anti-dysrhythmic drug?

A. Amiodarone
B. Bisoprolol
C. Digoxin
D. Propafenone
E. Sotalol
F. Verapamil

A

Answer: A. Amiodarone

Answer justification and feedback:
Amiodarone contains iodine and can cause both hypothyroidism and hyperthyroidism. Thyroid function tests should be carried out before treatment and every six months.

Resources:
RCGP. Curriculum Topic Guides: cardiovascular health. 2019.
BNF. Arrhythmias. https://bnf.nice.org.uk/treatment-summary/arrhythmias.html

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3
Q

For a person with heart disease who has developed nausea, vomiting, diarrhoea, disorientation, and weakness.

Which is the SINGLE MOST likely causative anti-dysrhythmic drug?

A. Amiodarone
B. Bisoprolol
C. Digoxin
D. Propafenone
E. Sotalol
F. Verapamil

A

Answer: C. Digoxin

Answer justification and feedback:
Digoxin toxicity is potentially serious and, if toxicity occurs, digoxin should be withdrawn. Serious manifestations require urgent specialist management.

Resources:
RCGP. Curriculum Topic Guides: cardiovascular health. 2019.
BNF. Arrhythmias. https://bnf.nice.org.uk/treatment-summary/arrhythmias.html

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4
Q

For a person with heart disease who has developed a rash when exposed to sunshine.

Which is the SINGLE MOST likely causative anti-dysrhythmic drug?

A. Amiodarone
B. Bisoprolol
C. Digoxin
D. Propafenone
E. Sotalol
F. Verapamil

A

Answer: A. Amiodarone

Answer justification and feedback:
Amiodarone has phototoxic potential. Patients should be advised to shield their skin from light.

Resources:
RCGP. Curriculum Topic Guides: cardiovascular health. 2019.
BNF. Arrhythmias. https://bnf.nice.org.uk/treatment-summary/arrhythmias.html

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5
Q

A 68-year-old man attends the surgery complaining of exertional aching chest pain for the last three weeks. He has a history of diabetes, hypertension and asthma. He is currently taking metformin, simvastatin, salbutamol and beclometasone inhalers. He smokes 30 cigarettes per day. On examination his blood pressure is 126/88 mmHg and his pulse is 102 beats/min and regular.

Which is the SINGLE MOST appropriate drug to use for this patient’s current symptoms? Select ONE option only.

A. Ramipril
B. Bisoprolol
C. Nicorandil
D. Isosorbide mononitrate
E. Diltiazem

A

Answer: E. Diltiazem

Answer justification and feedback:
This man has a likely diagnosis of angina and he should be referred to the rapid access chest pain clinic for confirmation of the diagnosis. Once the diagnosis has been established it would be recommended to prescribe a beta-blocker or calcium-channel blocker (CCB) as first-line regular treatment to reduce the symptoms of stable angina.

In this case a rate-limiting CCB (such as diltiazem) would be an ideal choice in view of the high resting pulse rate.

Beta-blockers, including those considered to be cardioselective, should usually be avoided in patients with a history of asthma, bronchospasm or a history of obstructive airways disease. If there was no alternative, a cardioselective beta-blocker can be given to these patients with caution and under specialist supervision. In such cases the risk of inducing bronchospasm should be appreciated and appropriate precautions taken.

If both beta-blockers and CCBs are contraindicated or not tolerated then a long acting nitrate such as isosorbide mononitrate can be used.

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6
Q

A 47-year-old Black Caribbean woman has been diagnosed with stage 2 hypertension. Her cardiovascular (CVD) risk is calculated at 21%.

According to the National Institute for Health and Care Excellence (NICE) guidelines, which is the SINGLE MOST appropriate antihypertensive therapy to commence? Select ONE option only.

A. Doxazosin
B. Amlodipine
C. Indapamide
D. Bisoprolol
E. Ramipril

A

Answer: B. Amlodipine

Answer justification and feedback:
NICE guidelines advise a calcium-channel blocker (CCB) to adults who are of black African or African–Caribbean family origin.

Resource:
NICE. Hypertension in Adults: diagnosis and management. NG136. 2019 (updated 2022).
https://www.nice.org.uk/guidance/ng136

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7
Q

An active 76-year-old man developed palpitations while walking his dog. The episode only lasted a few minutes and settled spontaneously. He had no chest pain and completed his walk without any further symptoms. Examination shows a regular pulse of 68 beats per minute, normal heart sounds and a blood pressure of 140/84 mmHg.

The results of his full blood count, renal function and electrolytes, thyroid function and blood glucose are normal. Although his resting 12-lead electrocardiogram was normal, an ambulatory monitor confirmed two short bursts of atrial fibrillation recorded over a 48-hour period.

Which SINGLE medication, if any, should be prescribed? Select ONE option only.

A. Apixaban
B. Aspirin
C. No medication indicated
D. Clopidogrel
E. Dipyridamole

A

Answer: A. Apixaban

Answer justification and feedback:
This patient’s CHA₂DS₂-VASc score of 2 indicates that he should be recommended oral anticoagulation to reduce his risk of stroke. Although he has paroxysmal atrial fibrillation (AF), his risk is similar to having continuous AF. Anticoagulation may be with apixaban, dabigatran etexilate, rivaroxaban or a vitamin K antagonist.

Antiplatelet agents are not recommended in the primary prevention of stroke.

Resource:
NICE. Atrial fibrillation: diagnosis and management. NG196. 2021 (updated 2021).
https://www.nice.org.uk/guidance/ng196

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8
Q

A 61-year-old woman with hypertension is taking amlodipine 5 mg daily. This is increased to 10 mg after four weeks as her blood pressure is not controlled. After two months at 10 mg, she returns for review when her blood pressure is 147/92 mmHg.

Which is the SINGLE MOST appropriate NEXT management step? Select ONE option only.

A. Add furosemide
B. Change to another calcium-channel blocker
C. Add bisoprolol
D. Continue with current treatment
E. Add ramipril

A

Answer: E. Add ramipril

Answer justification and feedback:
For patients under 80 years of age, the target clinic blood pressure is less than 140/90 mmHg, so additional treatment is required. Step 2 is to add an angiotensin converting enzyme (ACE) inhibitor, angiotensin-II receptor antagonist or a thiazide-like diuretic to the calcium-channel blocker.

Resource:
NICE. Hypertension in Adults: diagnosis and management. NG136. 2019 (updated 2022).
https://www.nice.org.uk/guidance/ng136

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9
Q

You are currently assessing a 67-year-old patient in your afternoon surgery, with first-episode cardiac sounding chest pain that started about eight hours ago whilst watching television, and lasted only 20 minutes. He is pain free at the moment and he has a normal resting 12-lead electrocardiogram (ECG).

What is the SINGLE MOST appropriate management option? Select ONE option only.

A. Reassurance with advice to return if pain recurs
B. Refer for same day assessment by the on-call medical team
C. Call an ambulance for immediate transfer to the emergency department
D. Prescribe sublingual glyceryl trinitrate (GTN)
E. Refer routinely to cardiology

A

Answer: B. Refer for same day assessment by the on-call medical team

Answer justification and feedback:
If acute coronary syndrome is suspected, refer patients to hospital as an emergency if they currently have chest pain or if they are currently free of pain but had chest pain in the last 12 hours and a resting 12-lead electrocardiogram (ECG) is abnormal or not available.

If you suspect acute coronary syndrome (ACS) and there are no reasons for emergency referral, refer for urgent same-day assessment if the chest pain started in the last 12 hours but the patient is now pain free with a normal ECG or if the last episode of pain was 12–72 hours ago.

Resource:
NICE CG95. 2010. https://www.nice.org.uk/guidance/cg95

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10
Q

During investigation for angina, a 45-year-old man has been found to have hypertrophic cardiomyopathy (HOCM). He has three teenage sons.

What is the SINGLE MOST appropriate course of action for his sons? Select ONE option only.

A. Arrange exercise tolerance tests
B. Arrange chest X-rays
C. Arrange electrocardiograms (ECGs)
D. Commence verapamil
E. Refer to a cardiologist

A

Answer: E. Refer to a cardiologist

Answer justification and feedback:
Cardiomyopathy is the most common inherited cardiovascular disease, affecting one in 500 of the general population. Most affected individuals are asymptomatic. Investigation of families is complex and requires specialist referral, genetic counselling, and testing.

Resource:
RCGP Curriculum Topic Guides: Cardiovascular Health. 2019.
https://www.rcgp.org.uk/mrcgp-exams/gp-curriculum/clinical-topic-guides#cardiovascular

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11
Q

A 58-year-old man presents with shortness of breath over the past five months. He notices this is worse with exertion and on lying down. The shortness of breath is associated with bilateral leg swelling. His past medical history includes a myocardial infarction (MI) about three years ago.

On examination, his heart sounds are normal and his chest is clear. There is mild bilateral pitting oedema to his ankles.

What is the MOST appropriate initial investigation of choice? Select ONE option only.

A. Electrocardiogram
B. Chest X-ray
C. Serum-natriuretic peptides
D. Transthoracic echocardiogram
E. Full blood count

A

Answer: C. Serum-natriuretic peptides

Answer justification and feedback:
NT-proBNP is the first-line test for suspected heart failure. High levels indicate the need for urgent echocardiography and specialist referral.

Resource:
NICE NG106. 2018. https://www.nice.org.uk/guidance/ng106

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12
Q

According to the deep vein thrombosis (DVT) Wells score, what is the MINIMUM calf swelling that should be present when considering a diagnosis of DVT? Select ONE option only.

A. Calf swelling at least 2 cm larger than asymptomatic side
B. Calf swelling at least 6 cm larger than asymptomatic side
C. Calf swelling at least 5 cm larger than asymptomatic side
D. Calf swelling at least 4 cm larger than asymptomatic side
E. Calf swelling at least 3 cm larger than asymptomatic side

A

Answer: E. Calf swelling at least 3 cm larger than asymptomatic side

Answer justification and feedback:
According to the Wells score, this is one of the key clinical features suggesting DVT.

Resource:
NICE NG158. 2020 (updated 2023). https://www.nice.org.uk/guidance/ng158

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13
Q

A 67-year-old man is diagnosed with chronic heart failure due to left ventricular systolic dysfunction. He was diagnosed with angina three years ago but has not experienced any chest pain since. His current treatment is:
- Bisoprolol 10 mg once daily
- Simvastatin 40 mg once daily
- Aspirin 75 mg once daily
- Glyceryl trinitrate (GTN) spray as needed (never used)

Which is the SINGLE MOST appropriate NEXT treatment step? Select ONE option only.

A. Hydralazine and nitrate
B. Angiotensin converting enzyme (ACE) inhibitor
C. Spironolactone
D. Calcium antagonist
E. Angiotensin-II receptor blocker

A

Answer: B. Angiotensin converting enzyme (ACE) inhibitor

Answer justification and feedback:
ACE inhibitors should be used first-line alongside beta-blockers for patients with heart failure due to LVSD.

Resource:
NICE NG106. 2018. https://www.nice.org.uk/guidance/ng106

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14
Q

A 68-year-old retired railway worker has chronic heart failure (CHF) secondary to ischaemic heart disease. He is already on an ACE inhibitor and his symptoms of exertional dyspnoea are well controlled.

According to best evidence, which of the following should you consider adding to his medication in order to reduce his risk of mortality due to CHF? Select ONE option only.

A. Furosemide
B. Isosorbide mononitrate
C. Bisoprolol
D. Flecainide
E. Atorvastatin

A

Answer: C. Bisoprolol

Answer justification and feedback:
Beta-blockers (e.g. bisoprolol) reduce mortality in heart failure and should be offered in addition to ACE inhibitors.

Resources:
RCGP, NICE NG106, SIGN 2016. http://www.sign.ac.uk/assets/sign147.pdf

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15
Q

A 69-year-old Afro-Caribbean man, with a long history of hypertension, developed ischaemic heart disease a year ago. His angina has not been well controlled and he is now on bisoprolol, nicorandil, ramipril, amlodipine and simvastatin. He is unable to take aspirin or clopidogrel due to gastrointestinal side effects. He presents with a history of intermittent tongue and lip swelling.

Which one of his drugs is the SINGLE MOST likely cause? Select ONE option only.

A. Amlodipine
B. Bisoprolol
C. Nicorandil
D. Ramipril
E. Simvastatin

A

Answer: D. Ramipril

Answer justification and feedback:
ACE inhibitors can cause angioedema, particularly in Afro-Caribbean patients.

Resource:
NICE NG106. 2018

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16
Q

A 50-year-old man has a blood pressure of 158/88 mmHg. He has no known atherosclerotic disease; but is keen to prevent it. He asks if he should take aspirin.

At which calculated absolute risk of a cardiovascular or cerebrovascular event is it appropriate to start aspirin 75 mg? Select ONE option only.

A. Greater than, or equal to, 10% over five years
B. Greater than, or equal to, 10% over 10 years
C. Greater than, or equal to, 20% over five years
D. Greater than, or equal to, 20% over 10 years
E. Not clinically indicated

A

Answer: E. Not clinically indicated

Answer justification and feedback:
Aspirin is not indicated for primary prevention due to the risk of bleeding outweighing benefits.

Resource:
NICE guidance

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17
Q

A 79-year-old woman is breathless and tired. She has bilateral ankle swelling and a triple rhythm on auscultation. Her ejection fraction on echocardiography is 35%.

Which of the following is the SINGLE MOST appropriate beta-blocker to prescribe for this patient? Select ONE option only.

A. Atenolol
B. Bisoprolol
C. Metoprolol
D. Propranolol
E. Sotalol

A

Answer: B. Bisoprolol

Answer justification and feedback:
Only bisoprolol, carvedilol and nebivolol are licensed for heart failure treatment.

Resource:
NICE NG106. 2018. https://www.nice.org.uk/guidance/ng106

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18
Q

An 80-year-old-man with angina has had an increase in the frequency of his angina over the past two months. His last episode was eight days ago and he has never had any rest pain. His blood pressure is 140/90 mmHg. He is taking amlodipine 10 mg daily and is intolerant of beta-blocker drugs.

Which is the SINGLE MOST appropriate ADDITIONAL drug treatment recommended to stabilise his condition? Select ONE option only.

A. Diltiazem
B. Felodipine
C. Isosorbide mononitrate
D. Nifedipine
E. Verapamil

A

Answer: C. Isosorbide mononitrate

Answer justification and feedback:
If beta-blockers and calcium-channel blockers are not tolerated, consider long-acting nitrates.

Resource:
NICE CG126. https://www.nice.org.uk/guidance/cg126

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19
Q

A 66-year-old man is breathless and tired. He has bilateral ankle swelling and a raised jugular venous pressure. His B-type natriuretic peptide (BNP) is elevated (600 pg/ml).

Which is the SINGLE MOST appropriate DIAGNOSTIC investigation? Select ONE option only.

A. Chest X-ray
B. Coronary angiogram
C. Echocardiogram
D. Electrocardiogram (ECG)
E. Exercise test

A

Answer: C. Echocardiogram

Answer justification and feedback:
The BNP is significantly raised, so echocardiography is recommended to confirm the likely diagnosis and can reliably differentiate between causes of heart failure.

Resource:
NICE. Chronic Heart Failure in Adults: diagnosis and management. NG106. 2018.
https://www.nice.org.uk/guidance/ng106

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20
Q

Your practice nurse asks for your advice about a 66-year-old woman with a venous ulcer. Her ankle brachial pressure index (ABPI) is normal.

Which of the following interventions has been shown to increase healing of her ulcer? Select ONE option only.

A. Antibiotics
B. Larvae
C. Non occlusive dressings
D. Compression hosiery
E. Exposure to air

A

Answer: D. Compression hosiery

Answer justification and feedback:
Compression hosiery should be routinely used for the treatment and prevention of the recurrence of leg ulcers. All other alternatives are of limited value unless specifically indicated.

Resource:
SIGN. Management of Chronic Venous Leg Ulcers. 2010.
https://www.sign.ac.uk/our-guidelines/management-of-chronic-venous-leg-ulcers/

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21
Q

A 63-year-old man has persistently raised clinic blood pressure and is referred for ABPM. His ABPM daytime average blood pressure is 140/90.

Which is the SINGLE MOST appropriate interpretation of this result? Select ONE option only.

A. Normal blood pressure
B. Stage 1 hypertension
C. Stage 2 hypertension
D. Stage 3 hypertension
E. White coat hypertension

A

Answer: B. Stage 1 hypertension

Answer justification and feedback:
This man’s ABPM daytime average blood pressure is above the threshold for stage 1 hypertension (135/85) but below the threshold for stage 2 hypertension (150/95).

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22
Q

A 70-year-old man is seen at home, following a fall, in a confused state. His daughter states he has been having episodes of confusion for several weeks. Over the last month, he has become increasingly tired and breathless. He has been off his food and lost weight. He has told her that he has been sweating profusely every night in bed.

On examination, his temperature is 37.8°C and heart rate 110 beats/min with a regular rhythm. He has a pansystolic murmur at the apex. No focal neurological signs can be elicited.

What is the SINGLE MOST likely reason for his confusion? Select ONE option only.

A. Subacute bacterial endocarditis
B. Encephalitis
C. Cerebral vasculitis
D. Subacute heart failure
E. Sub-dural haematoma

A

Answer: A. Subacute bacterial endocarditis

Answer justification and feedback:
The history and signs are highly suggestive of subacute bacterial endocarditis (SBE). The classical diagnostic triad is persistent fever, embolic events and new or changing murmurs. Emboli are most likely to be cerebral or renal.

Resource:
RCGP. Curriculum Topic Guides: cardiovascular health. 2019.

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23
Q

A 68-year-old man has heart failure and is treated with bisoprolol 10 mg and lisinopril 10 mg daily. He is struggling with a persistent dry cough and requests a change of treatment.

According to the National Institute for Health and Care Excellence (NICE) guidelines, which is the SINGLE MOST appropriate drug to switch this patient to INSTEAD of lisinopril? Select ONE option only.

A. Candesartan
B. Captopril
C. Nicorandil
D. Ramipril
E. Atenolol

A

Answer: A. Candesartan

Answer justification and feedback:
Patients intolerant of ACE inhibitors should be started on an angiotensin receptor blocker. Candesartan, losartan and valsartan are licensed for the first-line treatment of heart failure if an ACE inhibitor is unsuitable.

Resources:
RCGP. Cardiovascular health. 2019.
NICE NG106. Chronic heart failure in adults. 2018.

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24
Q

A 67-year-old man is diagnosed with chronic heart failure due to left ventricular systolic dysfunction. He was diagnosed with angina three years ago but has not experienced any chest pain since. His current treatment is:
- Bisoprolol 10 mg once daily
- Simvastatin 40 mg once daily
- Aspirin 75 mg once daily
- Glyceryl trinitrate (GTN) spray as needed (never used)

Which is the SINGLE MOST appropriate NEXT treatment step? Select ONE option only.

A. Hydralazine and nitrate
B. Angiotensin converting enzyme (ACE) inhibitor
C. Spironolactone
D. Calcium antagonist
E. Angiotensin-II receptor blocker

A

Answer: B. Angiotensin converting enzyme (ACE) inhibitor

Answer justification and feedback:
Offer beta-blockers licensed for heart failure with an ACE inhibitor to all patients with heart failure due to LVSD.

Resource:
NICE NG106. Chronic Heart Failure in Adults. 2018.

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25
A 58-year-old man with hypertension for four years is taking ramipril 10 mg and amlodipine 10 mg. At an annual review his blood pressure is 153/94 mmHg, 157/91 mmHg and 153/90 mmHg. Which is the SINGLE MOST appropriate NEXT management step? Select ONE option only. A. Add indapamide 2.5 mg B. Change amlodipine to felodipine 10 mg C. Change ramipril to candesartan 32 mg D. Add bendroflumethiazide 2.5 mg E. Continue his current therapy
Answer: A. Add indapamide 2.5 mg Answer justification and feedback: He is already on step 2 treatment with an ACE inhibitor and CCB. NICE recommends a thiazide-like diuretic such as indapamide or chlortalidone as the next step. Resource: NICE NG136. Hypertension in Adults. 2019 (updated 2022).
26
A 21-year-old man tells you that his brother has recently been diagnosed with familial hypercholesterolaemia (FH). Which ONE of the following lipid measurements is most useful, in association with DNA testing, to identify patients who have FH? Select ONE option only. A. High density lipoprotein (HDL) B. Low density lipoprotein cholesterol (LDL-C) C. Total cholesterol D. Triglycerides E. Very low density lipoprotein (VLDL)
Answer: B. Low density lipoprotein cholesterol (LDL-C) Answer justification and feedback: Guidelines recommend using cascade testing with DNA and LDL-C levels to identify affected relatives. Resources: NICE CG71 (2019), NG238 (2023)
27
Based on the information provided in each scenario, in which one of the following situations is four-layer compression bandaging (4LB) the SINGLE MOST appropriate management for a possible venous ulcer? Select ONE option only. A. A 52-year-old woman with longstanding bilateral lipodermatosclerosis. She has chronic depression. B. A 64-year-old woman with peripheral arterial disease. ABPIs: 0.6 (left), 0.75 (right). C. A 72-year-old man with CKD3 and Alzheimer’s. Ulcer has unusual features. D. A 49-year-old woman with COPD on prednisolone with fragile skin and falls. E. A 59-year-old man with diabetes, IHD, EF <35%, and oedema to knees.
Answer: A. A 52-year-old woman with longstanding bilateral lipodermatosclerosis Answer justification and feedback: Compression bandaging is appropriate for bilateral lipodermatosclerosis. Avoid if ABPI < 0.6 or if ulcer appears atypical. Resource: NICE CG147, SIGN
28
Which ONE of the following patients’ symptoms is LEAST LIKELY to be due to cardiomyopathy? Select ONE option only. A. A 56-year-old man with alcohol dependence syndrome complaining of swollen legs B. A 31-year-old woman post-partum with palpitations C. A 66-year-old man post-MI with breathlessness D. A 24-year-old woman with acromegaly and breathlessness E. A 49-year-old man with asthma exacerbation and palpitations
Answer: E. A 49-year-old man with asthma exacerbation and palpitations Answer justification and feedback: Cardiomyopathy can occur in alcohol misuse, postpartum state, MI, and endocrine conditions. Asthma does not directly cause cardiomyopathy.
29
Following coronary artery stenting, patients are started on dual antiplatelet therapy (DAPT). Which is the SINGLE MOST appropriate treatment for patients who had coronary stenting more than one year ago? Select ONE option only. A. Aspirin alone B. Aspirin and clopidogrel C. Aspirin and prasugrel D. Aspirin and rivaroxaban E. Aspirin and ticagrelor
Answer: A. Aspirin alone Answer justification and feedback: DAPT beyond 1 year increases bleeding risk without added benefit. Aspirin alone is recommended. Resources: Lancet 2014, NICE CKS 2023
30
A fit and active 66-year-old woman has suspected stable angina with a normal resting ECG. She is referred to secondary care. Which of the following investigations is LEAST helpful in diagnosis of stable angina? Select ONE option only. A. CT coronary angiography B. Stress echocardiogram C. Chest x-ray D. Myocardial perfusion scintigraphy E. Invasive coronary angiography
Answer: C. Chest x-ray Answer justification and feedback: Chest x-ray has limited value unless pulmonary disease is suspected. CT-CA or stress testing is preferred. Resource: NICE CG126. Stable Angina. 2016.
31
A 45-year-old man with tendinous xanthomata has a father who died of MI at age 46. Which of the following lipid profiles meets Simon Broome criteria for familial hypercholesterolaemia? Select ONE option only. A. TC > 5.3 mmol/l and LDL-C > 2.2 mmol/l B. TC > 6.0 mmol/l and LDL-C > 3.1 mmol/l C. TC > 6.7 mmol/L and LDL-C > 4.0 mmol/l D. TC > 7.5 mmol/l and LDL-C > 4.9 mmol/l E. TC < 8.2 mmol/l and LDL-C > 5.8 mmol/l
Answer: D. TC > 7.5 mmol/l and LDL-C > 4.9 mmol/l Answer justification and feedback: Simon Broome criteria require TC > 7.5 and LDL-C > 4.9 in adults plus tendon xanthomata or family history. Resource: NICE CG71. Familial Hypercholesterolaemia. 2019.
32
A 60-year-old woman seeks advice two weeks after CABG. BMI 30, ex-smoker. She asks what could reduce her mortality. Which ONE intervention reduces all-cause mortality by about one-third? Select ONE option only. A. Avoidance of heavy lifting B. Exercise-only rehabilitation C. Cognitive behavioural therapy D. Weight reduction to BMI 24 E. Alcohol <14 units/week
Answer: B. Exercise-only rehabilitation Answer justification and feedback: Exercise-only cardiac rehab reduces mortality by 27%. Recommended after MI or revascularisation. Resources: RCGP 2019, SIGN 2022
33
A 69-year-old man presents with 6 weeks of breathlessness. BP 154/86, HR 84. Normal heart sounds, clear chest, peripheral oedema to mid-shin. What is the SINGLE MOST appropriate INITIAL investigation? Select ONE option only. A. Serum natriuretic peptide B. Chest radiograph C. Full blood count D. Echocardiogram E. Pulmonary function tests
Answer: A. Serum natriuretic peptide Answer justification and feedback: Natriuretic peptides are the first-line investigation for suspected heart failure. Resource: NICE NG106. 2018.
34
A 65-year-old man has ABPM average 148/94 mmHg. ECG shows LVH. Fundoscopy and bloods normal. Cholesterol 6.3 mmol/L. What is the correct hypertension stage? Select ONE option only. A. Normotensive B. Stage 2 with target organ damage C. Stage 1 with target organ damage D. Stage 1 without target organ damage E. Stage 2 without target organ damage
Answer: C. Stage 1 with target organ damage Answer justification and feedback: Stage 1 = ABPM ≥135/85 and <150/95. Target organ damage includes LVH. Resource: NICE NG136. 2023.
35
A 77-year-old man has BP readings of 170/80, 174/76, 180/78. Home readings are similar. History of gout on allopurinol. Otherwise well. Which is the SINGLE MOST appropriate first-line antihypertensive? Select ONE option only. A. Ramipril B. Losartan C. Indapamide D. Amlodipine E. Doxazosin
Answer: D. Amlodipine Answer justification and feedback: CCB is preferred first-line in over 55s. Avoid thiazides in gout. Resource: NICE NG136. 2023.
36
A 79-year-old woman is breathless and tired. Bilateral ankle oedema. Triple rhythm on auscultation. EF 35%. Which is the SINGLE MOST appropriate beta-blocker to prescribe? Select ONE option only. A. Atenolol B. Bisoprolol C. Metoprolol D. Propranolol E. Sotalol
Answer: B. Bisoprolol Answer justification and feedback: Bisoprolol, carvedilol, and nebivolol are licensed for heart failure. Resource: NICE NG106. 2018.
37
A 79-year-old woman with EF 35% is already on a beta-blocker and ACE inhibitor. Which is the SINGLE MOST appropriate additional drug? Select ONE option only. A. Verapamil B. Amiodarone C. Furosemide D. Aspirin E. Valsartan
Answer: C. Furosemide Answer justification and feedback: Loop diuretics relieve congestion in HF. Titrate to symptoms. MRAs like spironolactone may also be needed. Resource: NICE NG106. 2018.
38
A 67-year-old woman has breathlessness, orthopnoea, and leg swelling. Echocardiogram shows preserved EF and diastolic dysfunction. What is the SINGLE MOST appropriate pharmacological option? Select ONE option only. A. Beta blockers B. ACE inhibitors C. Alpha blockers D. Diuretics E. Calcium channel blockers
Answer: D. Diuretics Answer justification and feedback: HFpEF is managed symptomatically. Diuretics relieve congestion; SGLT2 inhibitors may also help. Resources: NICE NG106. 2018, NICE CKS 2024.
39
A 75-year-old man has right calf pain after walking 200m. ABPI is 0.8 (right), 0.9 (left). Which is the SINGLE MOST appropriate medication to reduce cardiovascular risk? Select ONE option only. A. Aspirin 75 mg once daily B. Aspirin 75 mg + clopidogrel 75 mg once daily C. Aspirin 75 mg + dipyridamole 200 mg twice daily D. Clopidogrel 75 mg once daily E. Dipyridamole 200 mg twice daily
Answer: D. Clopidogrel 75 mg once daily Answer justification and feedback: Clopidogrel is preferred to aspirin for PAD. Dual therapy increases bleeding risk. Resource: NICE CG147. 2020.
40
A 70-year-old man with a family history of familial hypercholesterolaemia (FH) is being assessed. Which SINGLE lipid test is most appropriate to identify affected individuals during cascade testing? Select ONE option only. A. HDL B. LDL-C C. Total cholesterol D. Triglycerides E. VLDL
Answer: B. LDL-C Answer justification and feedback: Cascade testing uses LDL-C concentration and DNA testing to identify relatives with FH. Resources: NICE CG71. Familial Hypercholesterolaemia: identification and management. 2019.
41
A 60-year-old man with hypertension has been consulting you over the last few months. You have found that achieving optimal blood pressure control with medication has been difficult. His current treatment includes maximum doses of amlodipine, ramipril and indapamide. Blood tests show normal U&Es and potassium of 4.3 mmol/l. What medication would you introduce next? Select ONE option only. A. Bendroflumethiazide B. Spironolactone C. Clortalidone D. Doxazosin E. Candesartan
Answer: B. Spironolactone Justification: NICE guidance suggests spironolactone as fourth-line therapy for resistant hypertension if potassium is <4.5 mmol/L. If potassium is higher, consider higher-dose thiazide-like diuretics. Resource: NICE. Hypertension. CKS. 2023.
42
A 47-year-old woman with type 2 diabetes is diagnosed with hypertension and started on an ACE inhibitor. According to current national guidance, what is the clinic blood pressure target? Select ONE option only. A. 150/90 B. 140/90 C. 135/85 D. 130/85 E. 130/80
Answer: B. 140/90 Justification: The current universal clinic BP target for patients with hypertension under 80 years is <140/90 mmHg. Resource: NICE. Hypertension in adults: NG136. Updated 2023.
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A 38-year-old man has stage one hypertension and presents with headache and blurred vision. His BP is 210/124 mmHg and there may be papilloedema on fundoscopy. What is the MOST APPROPRIATE next step? Select ONE option only. A. Same day specialist advice B. Advice and guidance to hypertension clinic C. Referral to ophthalmology outpatient clinic D. Start antihypertensive and review in one week E. Referral to cardiology outpatient clinic
Answer: A. Same day specialist advice Justification: Signs of accelerated hypertension require urgent specialist assessment. Resource: NICE. Hypertension in adults: NG136. 2019 (updated 2023).
44
A 65-year-old man has a QRISK3 score of 14%. He agrees to start a statin. Which statin is first-line for primary prevention? Select ONE option only. A. Atorvastatin 80 mg B. Pravastatin 40 mg C. Rosuvastatin 10 mg D. Simvastatin 20 mg E. Atorvastatin 20 mg
Answer: E. Atorvastatin 20 mg Justification: NICE recommends atorvastatin 20 mg for primary prevention if 10-year CVD risk ≥10%. Resources: NICE NG238 (2023), SIGN 149 (2017).
45
Which drug is NOT usually recommended for rhythm control in atrial fibrillation? Select ONE option only. A. Diltiazem B. Amiodarone C. Cardioversion D. Flecainide E. Dronedarone
Answer: A. Diltiazem Justification: Diltiazem is primarily used for rate control, not rhythm control. Resource: NICE. Atrial fibrillation: NG196. 2021.
46
A 74-year-old Asian woman has type 2 diabetes, microalbuminuria, and BP around 154/94 mmHg. What is the PREFERRED FIRST-LINE antihypertensive? Select ONE option only. A. Atenolol B. Indapamide C. Amlodipine D. Losartan E. Ramipril
Answer: E. Ramipril Justification: ACEIs (or ARBs for Black patients) are first-line in diabetes with hypertension or CKD. Resources: NICE NG28 (2022), NG136 (2023).
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Which secondary prevention drug is recommended for microvascular angina? Select ONE option only. A. Aspirin B. Bisoprolol C. Ramipril D. Simvastatin E. No medication
Answer: E. No medication Justification: Routine secondary prevention drugs are not recommended for microvascular angina. Resource: NICE CG126. Updated 2016.
48
An 86-year-old woman has night foot pain. Her foot is dusky pink with no palpable pulses. She has shiny skin and hypertrophic toenails. What is her estimated 1-year risk of lower limb amputation? Select ONE option only. A. 5% B. 10% C. 30% D. 50% E. 70%
Answer: C. 30% Justification: Patients with rest pain have a ~33% risk of major amputation within a year. Resource: NICE CG147. 2020.
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Which of these is INCLUDED in the QRISK3 score? Select ONE option only. A. Personal history of ischaemic heart disease B. Impaired fasting glycaemia C. Family history of heart disease <70 years D. Personal history of rheumatoid arthritis E. Personal history of liver disease
Answer: D. Personal history of rheumatoid arthritis Justification: Rheumatoid arthritis is included in QRISK3; history of IHD excludes use of QRISK. Resource: QRISK3 tool.
50
A 52-year-old man has shoulder pain on exertion relieved by rest. How should this chest pain be classified? Select ONE option only. A. Unstable angina B. Non-anginal pain C. Prinzmetal angina D. Atypical angina E. Typical angina
Answer: E. Typical angina Justification: All 3 criteria met — exertional pain, constricting, relieved by rest/GTN in 5 mins. Resource: NICE CG95. Updated 2016.
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What is the clinic BP target for an 82-year-old man on amlodipine? Select ONE option only. A. <140/90 mmHg B. <160/90 mmHg C. <135/85 mmHg D. <150/90 mmHg E. <140/80 mmHg
Answer: D. <150/90 mmHg Justification: Target for patients ≥80 years is <150/90 mmHg. Resource: NICE NG136. 2023.
52
A 63-year-old man has breathlessness and ankle swelling. Which sign is MOST predictive of heart failure? A. Third heart sound B. Displaced apex C. Ejection systolic murmur D. Elevated JVP E. Tachycardia
Answer: D. Elevated JVP Justification: Elevated JVP is most predictive clinically of CHF. Resources: ESC 2021, BMJ 2000; 320:236.
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A 66-year-old woman has a venous leg ulcer and normal ABPI. What intervention improves healing? Select ONE option only. A. Non occlusive dressings B. Antibiotics C. Larvae D. Compression hosiery E. Exposure to air
Answer: D. Compression hosiery Justification: Compression improves healing and prevents recurrence. Resources: SIGN 2010, NICE CKS 2024.
54
A patient with hypertrophic cardiomyopathy and angina needs anti-anginal medication. Which drug should be AVOIDED? Select ONE option only. A. Bisoprolol B. Ranolazine C. Ivabradine D. Isosorbide mononitrate E. Nicorandil
Answer: D. Isosorbide mononitrate Justification: Nitrates reduce preload and worsen LVOT obstruction. Resource: InnovAiT 2020; 13(5): 297–305.
55
How is ABPI correctly calculated? Select ONE option only. A. Highest leg pressure / ipsilateral arm pressure B. Should not be done by HCA C. Ipsilateral arm pressure / affected leg pressure D. Average arm pressure / highest leg pressure E. Highest leg pressure / highest arm pressure
Answer: E. Highest leg pressure / highest arm pressure Justification: ABPI = ankle systolic / highest brachial systolic pressure. Resource: SVTGBI Guidelines, 2021.
56
A 54-year-old man with varicose veins has skin pigmentation. Which option is NOT recommended? Select ONE option only. A. Leg elevation B. Compression stockings as first line C. Vascular referral for ulcer >2 weeks D. Physical activity advice E. Vascular referral for pigmentation
Answer: B. Compression stockings as first line Justification: Compression is not first-line if referral is indicated. Resource: NICE CKS. Varicose veins. 2020.
57
A 28-year-old man with paroxysmal AF provoked by coffee has a CHA₂DS₂-VASc score of 0. What antithrombotic is recommended? Select ONE option only. A. Aspirin B. Warfarin C. Dabigatran D. No medication indicated E. Clopidogrel
Answer: D. No medication indicated Justification: No anticoagulation needed for CHA₂DS₂-VASc = 0. Resource: RCGP EKU15. Reviewed 2022.
58
A 57-year-old man starts HBPM. What is the correct protocol? Select ONE option only. A. Once daily for 7 days B. Twice daily for 7 days C. Once daily for 14 days D. Twice daily for 14 days E. Twice daily for 10 days
Answer: B. Twice daily for 7 days Justification: NICE recommends twice daily readings for at least 4 days, ideally 7. First day readings discarded. Resource: NICE NG136. 2023.
59
A 31-year-old man has intermittent palpitations. ECG shows delta wave and short PR. What is the diagnosis? Select ONE option only. A. WPW syndrome B. Brugada syndrome C. Excessive caffeine D. Ventricular ectopics E. Long QT syndrome
Answer: A. Wolff–Parkinson–White syndrome Justification: Delta wave and short PR suggest WPW. Risk of AF and life-threatening arrhythmias. Resource: EMJ 2003; 20:491–493.
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A 60-year-old man presents with exertional and nocturnal dyspnoea. He had an inferior MI 2 weeks ago. Exam reveals irregularly irregular pulse and pansystolic murmur at the apex. What is the MOST likely cause of the murmur? Select ONE option only. A. Pulmonary stenosis B. Aortic sclerosis C. Mitral regurgitation D. Aortic stenosis E. Tricuspid regurgitation
Answer: C. Mitral regurgitation Justification: Papillary muscle rupture post-MI can cause acute mitral regurgitation and pansystolic murmur. Resource: RCGP Curriculum: Cardiovascular Health. 2019.
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A 56-year-old man has recently been diagnosed with rheumatoid arthritis. He smokes 20 cigarettes a day. His average blood pressure is 150/90 mmHg, and his total cholesterol is 6.5 mmol/l. He currently takes no medication for his arthritis. According to current evidence, which drug is MOST likely to increase his cardiovascular risk? Select ONE option only. A. Hydroxychloroquine B. Azathioprine C. Sulphasalazine D. Methotrexate E. Prednisolone
Answer: E. Prednisolone Answer justification and feedback: Although steroids reduce inflammation, they are associated with increased cardiovascular risk, even at low doses. Resource: Pujades-Rodriguez M et al. PLoS Med 2022; 17(12): e1003432.
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A breathless male patient aged 70-years-old returns for the results of his echocardiogram. Which one of the statements below is true? Select ONE option only. A. An ejection fraction of 37% is normal B. Heart failure can be definitely excluded if his ejection fraction is 60% C. Heart failure can be definitely excluded if his ejection fraction is 90% D. If his ejection fraction is over 55% systolic function is preserved E. Diastolic dysfunction can be diagnosed by a reduction in ejection fraction
Answer: D. If his ejection fraction is over 55% systolic function is preserved Answer justification and feedback: LVEF >55% usually indicates preserved systolic function. HFpEF can still occur despite preserved EF. Resources: NICE NG106 (2018), SIGN 147 (2016).
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A 59-year-old man attends as a new patient to your practice. He was diagnosed with hypertension three years ago and is currently taking ramipril and simvastatin. He has no other medical conditions. What is the target clinic blood pressure reading for this patient? Select ONE option only. A. Less than 150/90 mmHg B. Less than 120/70 mmHg C. Less than 130/80 mmHg D. Less than 140/90 mmHg E. Less than 100/60 mmHg
Answer: D. Less than 140/90 mmHg Answer justification and feedback: The target clinic BP for adults under 80 with hypertension is <140/90 mmHg. Resource: NICE NG136. Updated 2023.
65
A 56-year-old man has chronic heart failure due to left ventricular systolic dysfunction. He has a previous MI. Current meds: Aspirin, Atenolol, Furosemide, Ramipril, Simvastatin. Which is the SINGLE MOST appropriate NEXT treatment step? Select ONE option only. A. Add losartan B. Change atenolol to bisoprolol C. Add spironolactone D. Increase ramipril dose E. Add isosorbide mononitrate and hydralazine
Answer: B. Change atenolol to bisoprolol Answer justification and feedback: Switch beta-blocker to one licensed for HF (bisoprolol, carvedilol, nebivolol). Resource: NICE NG106. 2018.
66
A 60-year-old man is taking atorvastatin 80 mg post-MI but has intolerable GI side effects. Which is the SINGLE MOST appropriate treatment option now? Select ONE option only. A. Add ezetimibe 10 mg B. Add fenofibrate 40 mg C. Continue on atorvastatin 80 mg D. Reduce to atorvastatin 40mg E. Stop the atorvastatin
Answer: D. Reduce to atorvastatin 40mg Answer justification and feedback: Use maximum tolerated dose of statin. Do not discontinue unless contraindicated. Resource: NICE CG181. Updated 2023.
67
A 36-year-old woman has familial hypercholesterolaemia. Which ONE is the MOST common clinical feature of familial hypercholesterolaemia? Select ONE option only. A. Truncal obesity B. Finger clubbing C. Cataracts D. Coarctation of the aorta E. Tendon xanthomata
Answer: E. Tendon xanthomata Answer justification and feedback: Tendon xanthomata on Achilles, fingers and feet are classic signs. Resource: NICE CG71. 2008 (updated 2019).
68
You assess a 67-year-old with first-episode chest pain 8 hours ago. Pain-free now with normal ECG. What is the SINGLE MOST appropriate management option? Select ONE option only. A. Refer routinely to cardiology B. Refer for same day assessment C. Prescribe GTN spray D. Reassure and advise return if pain recurs E. Call ambulance for immediate transfer
Answer: B. Refer for same day assessment Answer justification and feedback: ACS suspected → refer same day if <12h and ECG normal/pain-free. Resource: NICE CG95. 2016.
69
38-year-old patient with palpitations. ECG shows occasional ventricular ectopics. Lifestyle advice given but palpitations persist. What is the SINGLE MOST appropriate next step? Select ONE option only. A. Trial of verapamil B. Continue lifestyle changes C. Trial of bisoprolol D. Trial of amiodarone E. Flecainide 'pill in the pocket'
Answer: C. Trial of bisoprolol Answer justification and feedback: Beta-blockers can suppress benign ectopics in symptomatic patients. Resource: BNF. Arrhythmias; InnovAiT 2023.
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A 63-year-old woman has stable angina, type 2 diabetes and hypertension. Normal renal function, no albuminuria. What is the TARGET clinic BP? Select ONE option only. A. <140/90 mmHg B. <135/85 mmHg C. <125/75 mmHg D. <140/80 mmHg E. <130/75 mmHg
Answer: A. <140/90 mmHg Answer justification and feedback: Standard BP target in diabetes without albuminuria or CKD. Resource: NICE NG136. 2023.
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A 59-year-old man has ABPM average 145/92 mmHg. ECG, fundoscopy, bloods normal. CVD risk 26%. What is the SINGLE MOST appropriate antihypertensive treatment? Select ONE option only. A. No treatment indicated B. Prescribe a beta-blocker C. Prescribe a calcium-channel blocker D. Prescribe a diuretic E. Prescribe an ACE inhibitor
Answer: C. Prescribe a calcium-channel blocker Answer justification and feedback: Over age 55 with stage 1 HTN and CVD risk ≥10% → start CCB. Resource: NICE NG136. 2022.
72
A 66-year-old man with HTN and CKD stage 3 has ACR 35 mg/mmol. BP uncontrolled on lifestyle. What is the SINGLE MOST appropriate first-line antihypertensive? Select ONE option only. A. Indapamide B. Doxazosin C. Atenolol D. Ramipril E. Amlodipine
Answer: D. Ramipril Answer justification and feedback: ACE inhibitors reduce proteinuria and protect renal function in CKD with ACR >30. Resources: NICE NG203. 2021; InnovAiT 2020.
73
A 59-year-old man with BP readings 176/95 and 174/94 on same day. Asymptomatic. What is the SINGLE MOST appropriate initial management? Select ONE option only. A. Start antihypertensive treatment B. Refer for same-day secondary care C. Arrange home blood pressure monitoring D. Recheck BP within one week E. Recheck BP in one month
Answer: C. Arrange home blood pressure monitoring Answer justification and feedback: Confirm stage 1 HTN with HBPM or ABPM. Resource: NICE NG136. 2023.
74
A 62-year-old patient with polymyalgia rheumatica reports persistent headache and right facial pain. What is the MOST likely diagnosis? Select ONE option only. A. Brain tumour B. Trigeminal Neuralgia C. Migraine D. TMJ dysfunction E. Giant cell (temporal) arteritis
Answer: E. Giant cell (temporal) arteritis Answer justification and feedback: Associated with PMR. Headache, facial pain and jaw claudication are key signs. Resources: NICE CKS 2022; InnovAiT 2023.
75
A 73-year-old woman with metallic mitral valve feels unwell. Temp 38.5°C, murmur noted. No clear focus of infection. What is the SINGLE MOST appropriate management? Select ONE option only. A. Advise paracetamol and ibuprofen B. Advise self-care C. Start phenoxymethylpenicillin 10 days D. Discuss with secondary care E. Start 5-day course of co-amoxiclav
Answer: D. Discuss with secondary care Answer justification and feedback: High risk of infective endocarditis with prosthetic valve and fever. Resource: NICE CG64. 2016.
76
Match investigation to scenario: - Patient 1: 75F, episodic palpitations, normal ECG - Patient 2: 55M, exertional chest tightness, normal ECG - Patient 3: 70M, vague backache, obese, father died suddenly Select the MOST appropriate investigation for each. A. 24-hr ECG / CT-CA / Abdo US B. Abdo US / CT-CA / 24-hr ECG C. CT-CA / Abdo US / 24-hr ECG D. 24-hr ECG / Abdo US / CT-CA E. CT-CA / 24-hr ECG / Abdo US
Answer: A. 24-hr ECG / CT-CA / Abdo US Answer justification and feedback: 24-hr ECG for episodic arrhythmias, CT-CA for suspected angina, Abdo US for AAA suspicion. Resources: NICE CG95; RCGP 2019.
77
A 52-year-old man has QRISK3 = 12%. Already had dietary advice, no meds. What is the SINGLE MOST appropriate medication? Select ONE option only. A. Atorvastatin 20 mg B. Atorvastatin 40 mg C. Atorvastatin 80 mg D. Simvastatin 20 mg E. Simvastatin 40 mg
Answer: A. Atorvastatin 20 mg Answer justification and feedback: Recommended first-line for primary prevention if 10-year CVD risk ≥10%. Resource: NICE NG238. 2023.
78
56-year-old man asks which lifestyle change reduces CVD risk most. What is the MOST beneficial target? Select ONE option only. A. 60 mins physical activity per week B. 75 mg aspirin daily C. 400 g fruit/veg per day D. Reduce BMI to 25 E. Reduce dietary saturated fat by 20 g
Answer: D. Reduce BMI to 25 Answer justification and feedback: 3 kg weight loss can reduce CVD risk by up to 50%. Resource: InnovAiT 2019; 12(3): 117–122.
79
A 64-year-old with cardiac sounding chest pain. ECG shows STEMI. Which description matches ECG findings in STEMI? Select ONE option only. A. ST elevation >1mm in any one lead B. ST elevation >2mm in any lead or new RBBB C. ST elevation >1mm in 2 contiguous leads or new LBBB D. ST elevation >2mm in 1 contiguous lead or new LBBB E. ST elevation >1mm in 1 contiguous lead or new LBBB
Answer: C. ST elevation >1mm in 2 contiguous leads or new LBBB Answer justification and feedback: STEMI = ST elevation >1mm in 2+ contiguous leads or new LBBB. Resource: InnovAiT 2023; 16(3): 120–125.
80
A 79-year-old sedentary man has newly diagnosed AF. Which ONE medication is appropriate for rate control? Select ONE option only. A. Digoxin B. Clopidogrel C. Sotalol D. Doxazosin E. Amiodarone
Answer: A. Digoxin Answer justification and feedback: Digoxin suitable for sedentary patients with non-paroxysmal AF. Resource: NICE NG196. 2021.
81
A person with heart disease has gained weight, feels very tired, and cold. Which is the SINGLE MOST likely causative anti-arrhythmic drug? A. Amiodarone B. Bisoprolol C. Digoxin D. Flecainide E. Propafenone F. Verapamil
Answer: A. Amiodarone Answer justification and feedback: Amiodarone contains iodine and can cause both hypothyroidism and hyperthyroidism. TFTs should be monitored every 6 months. Resource: BNF. Anti-arrhythmic drugs.
82
A person with heart disease has developed nausea, vomiting, diarrhoea, disorientation and weakness. Which is the SINGLE MOST likely causative anti-arrhythmic drug? A. Amiodarone B. Bisoprolol C. Digoxin D. Flecainide E. Propafenone F. Verapamil
Answer: C. Digoxin Answer justification and feedback: These symptoms suggest digoxin toxicity, which requires urgent withdrawal and specialist management. Resource: BNF. Anti-arrhythmic drugs.
83
A person with heart disease has developed a rash when exposed to sunshine. Which is the SINGLE MOST likely causative anti-arrhythmic drug? A. Amiodarone B. Bisoprolol C. Digoxin D. Flecainide E. Propafenone F. Verapamil
Answer: A. Amiodarone Answer justification and feedback: Amiodarone can cause phototoxic reactions. Advise patients to shield skin from light. Resource: BNF. Anti-arrhythmic drugs.
84
A 60-year-old man attends for a review of his medication following a myocardial infarction two weeks ago. He is asymptomatic and has normal ventricular function. His current medication includes aspirin 75 mg, clopidogrel 75 mg, ramipril 10 mg and atorvastatin 80 mg. Which ADDITIONAL drug should be considered for this patient? Select ONE option only. A. Nicorandil B. Spironolactone C. Bisoprolol D. Furosemide E. Amlodipine
Answer: C. Bisoprolol Answer justification and feedback: Following MI, patients should be treated with ACE inhibitors, statins, dual antiplatelet therapy and beta-blockers. Beta-blockers reduce mortality and are indicated in patients without contraindications. Resource: NICE. Acute coronary syndromes. NG185. 2020.
85
An active 71-year-old man, who has recently had a small TIA, is diagnosed as having non-valvular atrial fibrillation. He reports uncomfortable palpitations and chest pain on exertion. Which ONE medication could be prescribed to control his symptoms, assuming no contraindications? Select ONE option only. A. Amiodarone B. Amlodipine C. Bisoprolol D. Digoxin E. Flecainide
Answer: C. Bisoprolol Answer justification and feedback: For active older adults with symptomatic AF, rate control with a beta-blocker is appropriate. Digoxin is best for sedentary patients. Resources: NICE. Atrial fibrillation: diagnosis and management. NG196. 2021. RCGP Curriculum Topic Guides: cardiovascular health. 2019.
86
A 39-year-old man is worried about a pulmonary embolus. He has no thromboembolic risk factors. Which score is MOST appropriate to rule out a PE? Select ONE option only. A. HASBLED B. ABCD2 C. 2-level Wells D. Barthel E. PERC
Answer: E. PERC Justification: PERC is used in low-risk patients to rule out PE without a D-dimer. Resource: NICE. Venous thromboembolic diseases. NG158. 2023.
87
Which is the SINGLE MOST likely antihypertensive drug to cause gynaecomastia? Select ONE option only. A. Amlodipine B. Indapamide C. Doxazosin D. Spironolactone E. Ramipril
Answer: D. Spironolactone Justification: Spironolactone has antiandrogenic effects, leading to gynaecomastia. Resource: BNF; NICE NG136.
88
A 59-year-old man presents three weeks after MI with fever, chest pain that improves on sitting forward, and a pericardial rub. What is the SINGLE MOST likely cause? Select ONE option only. A. Dressler’s syndrome B. Unstable angina C. Pulmonary embolus D. Acute MI E. Aortic dissection
Answer: A. Dressler’s syndrome Justification: Autoimmune pericarditis post-MI, typically 3–10 weeks later. Resource: RCGP Curriculum: Cardiovascular health. 2019.
89
A 72-year-old has HFrEF. Current treatment: furosemide and ramipril. What is the SINGLE MOST appropriate next treatment? Select ONE option only. A. Beta blocker B. Thiazide diuretic C. Digoxin D. Spironolactone E. Nitrate
Answer: A. Beta blocker Justification: Beta blockers (bisoprolol or carvedilol) improve survival in HFrEF and should be added after ACE inhibitors. Resource: NICE NG106. 2018.
90
A 74-year-old man has raised NT-proBNP and suspected HF. He also has high BP and T2DM. Which medication should be AVOIDED? Select ONE option only. A. Candesartan B. Ramipril C. Doxazosin D. Furosemide E. Amlodipine
Answer: C. Doxazosin Justification: Doxazosin may worsen HF and should be avoided. Resource: InnovAiT 2022; 15(12): 706–711.
91
A 50-year-old Bangladeshi man has a QRISK2 of 12%. Which is the MOST appropriate lipid modification therapy? Select ONE option only. A. Bezafibrate 600 mg B. Ezetimibe 10 mg C. Atorvastatin 20 mg D. Rosuvastatin 10 mg E. Simvastatin 40 mg
Answer: C. Atorvastatin 20 mg Justification: NICE recommends atorvastatin 20 mg for primary prevention with ≥10% risk. Resource: NICE CG181. Updated 2023.
92
A 68-year-old woman had an uncomplicated MI and is allergic to aspirin. Which drug is the MOST appropriate for lifelong secondary prevention? Select ONE option only. A. Ticagrelor B. Prasugrel C. Clopidogrel D. Warfarin E. Dipyridamole
Answer: C. Clopidogrel Justification: Clopidogrel is the alternative to aspirin when contraindicated. Resource: NICE NG185. 2020.
93
You see a 63-year-old with AF awaiting hernia repair. What is the SINGLE MOST important objective for GP management pre-surgery? Select ONE option only. A. INR control B. Managing anticoagulants C. Rate control D. Rhythm control E. Managing comorbidities
Answer: C. Rate control Justification: Rate control optimises cardiac output pre-op and is a primary GP responsibility. Resource: InnovAiT 2022; 15(11): 652–660.
94
A 50-year-old man with BP 158/88 mmHg asks about aspirin for prevention. At what absolute risk is aspirin indicated? Select ONE option only. A. ≥10% over 5 years B. ≥10% over 10 years C. ≥20% over 5 years D. ≥20% over 10 years E. Not clinically indicated
Answer: E. Not clinically indicated Justification: Aspirin is not recommended for primary prevention due to bleeding risk. Resource: NICE NG238. 2023.
95
A 35-year-old woman has secondary hypertension. Which is the MOST likely cause? Select ONE option only. A. Addison’s disease B. Coeliac disease C. Renal artery stenosis D. Diabetes insipidus E. Hypopituitarism
Answer: C. Renal artery stenosis Justification: Most common cause of secondary hypertension in younger patients. Resource: NICE NG136. 2023.
96
A 56-year-old man with angina is on bisoprolol 10 mg daily. HR 60 bpm, BP 140/82 mmHg, but still gets chest pain. What is the MOST appropriate ADDITIONAL therapy? Select ONE option only. A. Nicorandil B. Ranolazine C. Isosorbide mononitrate D. Amlodipine E. Diltiazem
Answer: D. Amlodipine Justification: Add a dihydropyridine calcium-channel blocker if symptoms persist despite adequate beta blockade. Resources: NICE CG126 (2016); RCGP CAD module (2024).
97
Which condition makes formal CVD risk assessment unnecessary? Select ONE option only. A. Rheumatoid arthritis B. High blood pressure C. Type 2 diabetes D. Atrial fibrillation E. Chronic kidney disease stage 3
Answer: E. Chronic kidney disease stage 3 Justification: CKD stage 3 is considered high-risk and warrants treatment without risk assessment. Resources: NICE NG238 (2023), CKS CVD risk (2023).
98
A 65-year-old man with chronic heart failure reports developing breast tissue. Which drug is MOST likely responsible? Select ONE option only. A. Bisoprolol B. Digoxin C. Furosemide D. Perindopril E. Spironolactone
Answer: E. Spironolactone Justification: Spironolactone commonly causes gynaecomastia; switch to eplerenone if needed. Resource: BNF; NICE NG106 (2018).
99
A 75-year-old woman has bilateral varicose veins with pigmentation. Past MI, hypertensive, smoker. What is the MOST appropriate option? Select ONE option only. A. Refer to vascular clinic B. Prescribe emollients C. Start trial of diuretic therapy D. Prescribe compression bandaging E. Assess smoking status
Answer: A. Refer to vascular clinic Justification: Skin changes with varicosities require referral for assessment and intervention. Resource: NICE CG168. 2013.
100
A 34-year-old man has intermittent palpitations. BP is 154/98 mmHg. What is the MOST appropriate immediate assessment step? Select ONE option only. A. 24 hr urinary metanephrines B. Ambulatory BP monitoring C. Home BP monitoring D. Measure BP 2–3 times in consultation E. ECG
Answer: D. Measure BP 2–3 times in consultation Justification: NICE recommends repeated BP in same consultation to confirm raised clinic reading. Resource: NICE NG136. 2023.
101
A 75-year-old woman with HFrEF and well-controlled symptoms has BP 154/92 mmHg on several occasions. Current treatment includes: aspirin, furosemide, bisoprolol, perindopril, atorvastatin. What is the SINGLE MOST appropriate ADDITIONAL treatment? Select ONE option only. A. Verapamil B. Amlodipine C. Nimodipine D. Diltiazem E. Nifedipine
Answer: B. Amlodipine Justification: Amlodipine may be added for hypertension in HF patients; avoid verapamil/diltiazem. Resources: BNF; NICE NG106 and NG136.
102
Which of the following CKD and T2DM patients has BP in the target range? A. 85yo, BP 152/95, ACR 0.1 mg/mmol B. BP 138/84, ACR 30 mg/mmol C. BP 142/74, ACR 0.5 mg/mmol D. BP 154/76, ACR 7 mg/mmol E. BP 136/72, ACR 73 mg/mmol
Answer: B. BP 138/84, ACR 30 mg/mmol Justification: For ACR <70, aim for BP <140/90. Option B fits. Resources: NICE NG203 (2021), NG136 (2023).
103
A 64-year-old woman has 4-month exertional SOB, orthopnoea, and ankle swelling. What is the SINGLE MOST appropriate initial investigation? Select ONE option only. A. Inhaled corticosteroid trial B. Chest x-ray C. NT-proBNP D. Lung function tests E. Salbutamol trial
Answer: C. NT-proBNP Justification: Raised BNP suggests heart failure. First-line test when HF is suspected. Resource: InnovAiT 2022; 15(12): 706–711.
104
You see a 56-year-old man who asks you about abdominal aortic aneurysm screening after hearing a radio news item. Which ONE of the following statements regarding AAA screening in the UK is correct? A. The programme is available to men aged 65 years B. The screening programme is also offered to cisgender women C. Women are three times more likely to have an AAA than men D. An AAA is defined as an aortic diameter of at least 5 mm E. NICE is responsible for assessing the evidence for screening programmes
Answer: A. The programme is available to men aged 65 years Justification: The UK AAA screening programme targets men aged 65. The UK National Screening Committee (UK NSC) evaluates screening evidence. An AAA is defined as a diameter ≥3 cm. Resource: PHE. NHS AAA programme. 2023.
105
You see a 23-year-old bakery worker who collapsed at work. He had dizziness, nausea, palpitations, pallor, and sweating. He lost consciousness for a few minutes and fully recovered in a few hours. What is the SINGLE MOST likely diagnosis? A. Supraventricular tachycardia (SVT) B. Carotid sinus syndrome C. Vasovagal syncope D. Orthostatic hypotension E. Epilepsy
Answer: C. Vasovagal syncope Justification: Preceding nausea, pallor, dizziness, and recovery within minutes suggest vasovagal syncope. Common triggers include heat, standing, and stress. Resource: Siddiqui DZA, Ali DAM. InnovAiT 2024; 17(7): 334–338.
106
A 54-year-old woman with resistant hypertension is on max dose amlodipine, indapamide and ramipril. ABPM = 147/92. Potassium = 4.9 mmol/l. What is the SINGLE MOST appropriate management? A. Increase ramipril dose beyond max B. Add spironolactone C. Adequate BP control, no change D. Add digoxin E. Add alpha- or beta-blocker
Answer: E. Add alpha- or beta-blocker Justification: For potassium >4.5 mmol/L, NICE recommends adding an alpha- or beta-blocker at step 4. Resource: NICE NG136. Hypertension. 2023.
107
A 61-year-old man has ABPI of 1.09. What is the correct interpretation? A. Calcified limb arteries B. Critical limb ischaemia C. Popliteal aneurysm D. Normal result E. Arterial disease
Answer: D. Normal result Justification: ABPI between 1.0–1.4 is considered normal. Values >1.4 suggest calcification. <0.9 suggests PAD. Resources: NICE CG147 (2020); NICE CKS PAD 2024.
108
A 72-year-old woman post-MI is on aspirin, atorvastatin, and ramipril. BP 130/74. Echo is normal. What is the SINGLE MOST appropriate additional drug? A. Digoxin B. Losartan C. Bisoprolol D. Amlodipine E. Spironolactone
Answer: C. Bisoprolol Justification: Beta-blockers reduce post-MI mortality and are recommended unless contraindicated. Resource: NICE NG185. Acute coronary syndromes. 2020.
109
A 57-year-old man has BP readings of 193/113 and 189/111. He has chest pain and ankle swelling. ECG and renal function are normal. What is the SINGLE MOST appropriate INITIAL management? A. Refer for same-day secondary care B. Recheck BP in one week C. Start ramipril D. Start amlodipine E. 24 hr urinary metanephrines
Answer: A. Refer for same-day secondary care Justification: BP >180/120 with signs of target organ damage warrants urgent referral. Resource: NICE NG136. Hypertension. 2023.
110
Elderly man with long-standing claudication now has worsening pain and has used dihydrocodeine. What is a feature of critical limb ischaemia? A. ABPI of 1 B. Nail dystrophy C. Popliteal bruit D. Increased skin temperature E. Rest pain
Answer: E. Rest pain Justification: Rest pain indicates ischaemia of skin/tissue and suggests critical limb ischaemia. Resource: NICE CG147. PAD. 2020.
111
Which patient is QRISK3 MOST likely to underestimate CVD risk? A. 55F with diabetes B. 50M South-Asian, BMI 26 C. 67F with AF and HTN D. 49M with psoriatic arthritis, smokes E. 41M with CKD and cholesterol:HDL 4.1
Answer: D. 49M with psoriatic arthritis, smokes Justification: QRISK3 may underestimate risk in inflammatory conditions like psoriatic arthritis. Resource: RCGP Learning; NICE NG238.
112
An 80-year-old man with angina is intolerant of beta-blockers and takes amlodipine 10 mg. BP 140/90. Angina frequency has increased. Which drug should be added? A. Diltiazem B. Felodipine C. Isosorbide mononitrate D. Nifedipine E. Verapamil
Answer: C. Isosorbide mononitrate Justification: In patients intolerant to both beta-blockers and CCBs, long-acting nitrates are second-line. Resource: NICE CG126. Stable angina. 2016.
113
A 78-year-old woman has AF diagnosed on ECG with HR 116 bpm. Asymptomatic. BP 146/90. After anticoagulation, what is the NEXT step? A. Prescribe amiodarone B. Prescribe sotalol C. Admit as medical emergency D. Prescribe flecainide E. Prescribe bisoprolol
Answer: E. Prescribe bisoprolol Justification: Start beta-blocker or rate-limiting CCB for rate control in primary care. Rhythm control drugs need specialist input. Resource: NICE NG196. AF. 2021.
114
A 58-year-old faints while shaving. What is the SINGLE MOST likely diagnosis? A. Epilepsy B. Orthostatic hypotension C. Vasovagal syncope D. Atrial fibrillation E. Carotid sinus syndrome
Answer: E. Carotid sinus syndrome Justification: Shaving triggers carotid sinus via baroreceptor reflex → bradycardia + hypotension. Resource: Siddiqui DZA, Ali DAM. InnovAiT 2024; 17(7): 334–338.
115
A 22-year-old Filipino student collapses in class. ECG shows coved ST elevation in V1–V2. Father died in sleep aged 32. What is the SINGLE MOST appropriate management? A. Refer for 24hr BP monitoring B. Start beta-blocker C. Refer for 24hr ECG D. Same-day expert cardiology assessment E. Reassure patient
Answer: D. Same-day expert cardiology assessment Justification: Brugada syndrome suspected → high risk of sudden death. Requires ICD consideration. Resource: ESC Guidelines. Ventricular Arrhythmias. 2022.
116
65M with cholesterol 6.2, LDL 4.1, triglycerides 4.0. CVD risk 21%. What is the MOST appropriate next step? A. Add ezetimibe B. Add fenofibrate C. Add atorvastatin D. Add omega-3 E. Continue dietary advice
Answer: C. Add atorvastatin Justification: Offer atorvastatin 20 mg for primary prevention if CVD risk ≥10%. Resource: NICE CG181. Updated 2023.
117
45-year-old man diagnosed with HOCM. He has 3 teenage sons. What is the MOST appropriate action? A. Arrange exercise tolerance tests B. Arrange chest x-rays C. Arrange ECGs D. Start verapamil E. Refer to cardiologist
Answer: E. Refer to cardiologist Justification: Inherited cardiomyopathies require specialist referral for family screening. Resource: RCGP. Curriculum: Cardiovascular Health. 2019.
118
Which BP range is associated with the LOWEST CV events in stable CAD? A. 100/60 – 129/69 B. 110/60 – 129/69 C. 110/60 – 139/79 D. 120/70 – 139/79 E. 120/70 – 139/89
Answer: D. 120/70 – 139/79 Justification: Extremes of BP (too low or too high) increase CV risk — J-shaped curve. Resource: RCGP Learning; NICE NG136.
119
Which patient is NOT suitable for Wells score DVT assessment? A. Recent travel B. Pregnancy or puerperium C. Renal disease D. Possible PE E. Cancer
Answer: B. Pregnancy or puerperium Justification: Wells score should not be used in pregnancy — refer same day. Resource: Allen L, Wilkinson A. InnovAiT 2020; 13(6): 344–351.
120
47F Black Caribbean woman, stage 2 HTN, CVD risk 21%. What is the FIRST-LINE antihypertensive? A. Amlodipine B. Doxazosin C. Bisoprolol D. Indapamide E. Ramipril
Answer: A. Amlodipine Justification: In Black African or Caribbean adults without diabetes → CCB first-line. Resource: NICE NG136. 2023.
121
51F Black African, T2DM, stage 2 hypertension. What is the most appropriate FIRST-LINE treatment? A. Amlodipine B. Doxazosin C. Ramipril D. Losartan E. Indapamide
Answer: D. Losartan Justification: Use ARB in preference to ACEi for Black African patients with T2DM. Resource: NICE NG136. 2023.
122
62M Afro-Caribbean, BP 168/96. No comorbidities. What is the SINGLE MOST appropriate antihypertensive to start? A. Valsartan B. Doxazosin C. Bisoprolol D. Amlodipine E. Ramipril
Answer: D. Amlodipine Justification: CCB first-line for people of African/Caribbean origin unless T2DM. Resource: NICE NG136. 2023.
123
68M, BP 192/123, no chest pain/confusion/HF, but retinal haemorrhage on exam. What is the SINGLE MOST appropriate management? A. Repeat BP within 1 week B. Routine referral C. Start antihypertensive now D. Urgent same-day specialist assessment E. Arrange ABPM
Answer: D. Urgent same-day specialist assessment Justification: BP >180/120 with retinal signs → emergency secondary care assessment. Resources: NICE NG136 (2023); NICE CKS Hypertension (2023).
124
After abnormal blood pressure readings (137/92 mmHg, 143/89 mmHg, 141/91 mmHg) at a routine check, a 49-year-old woman has had ambulatory blood pressure monitoring (ABPM). The result of this shows an average daytime blood pressure of 134/82 mmHg. Which is the SINGLE MOST appropriate NEXT management option? Select ONE option only. A. No treatment but recheck blood pressure next year B. No treatment but regular three-monthly blood pressure check in nurse clinic C. No treatment or follow-up required D. Prescribe angiotensin converting enzyme (ACE) inhibitor E. Prescribe calcium-channel blocker
Answer: A. No treatment but recheck blood pressure next year Answer justification and feedback: If average daytime ABPM is under 135/85 mmHg, the patient is not hypertensive. Blood pressure should be rechecked within the next five years, more frequently if close to 140/90 mmHg. Lifestyle advice is recommended. Resource: NICE Hypertension Guidelines
125
A 73-year-old lady is self-conscious about her asymptomatic right leg varicose veins. Exam is unremarkable. Which is the SINGLE MOST appropriate initial management option? Select ONE option only. A. Refer directly for doppler ultrasound assessment B. Refer to a vascular surgeon for further investigation C. Measure the patient and prescribe below knee compression hosiery D. Refer to the vascular surgeon for varicose vein intervention E. Offer explanation, information and reassurance
Answer: E. Offer explanation, information and reassurance Answer justification and feedback: NICE recommends explanation and reassurance for uncomplicated, asymptomatic varicose veins. Referral is only indicated if symptoms or complications are present. Resources: NICE CG168 (2013); NICE CKS Varicose Veins (2024)
126
A 62-year-old man with COPD presents with worsening SOB and leg swelling. NT-proBNP = 1600 pg/ml. What is the SINGLE MOST appropriate management plan? Select ONE option only. A. Send the patient for an electrocardiogram and chest x-ray B. Refer to cardiology for an echocardiogram within 6 weeks C. Start the patient on spironolactone D. Refer to cardiology for an echocardiogram within 2 weeks E. Reassure the patient. The raised blood test result is due to COPD
Answer: B. Refer to cardiology for an echocardiogram within 6 weeks Answer justification and feedback: NT-proBNP between 400–2000 indicates likely heart failure. Refer for echo within 6 weeks. COPD can raise NT-proBNP, but symptoms require investigation. Resources: NICE NG106 (2018); Bignell et al., InnovAiT 2020
127
What is the SINGLE MOST appropriate treatment for rate control in a patient with persistent atrial fibrillation (AF) with congestive heart failure? A. Verapamil B. Amiodarone C. Nicorandil D. Bisoprolol E. Aspirin
Answer: D. Bisoprolol Answer justification and feedback: Beta-blockers are first-line for rate control in AF with HF. Verapamil is contraindicated. Resource: NICE NG196 (2021)
128
A 64-year-old woman has right-sided calf pain on walking uphill, no rest pain, PMH includes RA and obesity. What is the most appropriate initial investigation? A. Contrast-enhanced magnetic resonance angiography B. Full blood count C. Computerised tomography (CT) angiography D. Ankle-brachial pressure index E. Duplex ultrasound
Answer: D. Ankle-brachial pressure index Answer justification and feedback: ABPI is initial test for PAD in primary care. Value <0.8 suggests PAD. Duplex US is for pre-revascularisation assessment. Resource: NICE CG147 (2020)
129
A 58-year-old man with peripheral arterial disease presents with worsening right leg pain for 2 days. Exam: cold, pale leg, no pulses. What is the SINGLE MOST appropriate management? A. Routine referral to vascular surgery B. Same-day referral to vascular surgery C. Commence anticoagulation D. Arrange duplex ultrasound E. Prescribe 300 mg aspirin
Answer: B. Same-day referral to vascular surgery Answer justification and feedback: Acute limb ischaemia needs urgent referral. Symptoms: pain, pallor, cold limb, paraesthesia, pulselessness, paralysis. Resource: NICE CG147 (2020)
130
Management of hypertension scenarios: 1. 40F Afro-Caribbean, BP ~180/110, normal bloods/urine 2. 50M Indian, on ramipril 5 mg, coughing 3. 81M on ramipril 10 mg + indapamide 2.5 mg, uncontrolled BP, no postural drop, normal bloods Which medications? A. Amlodipine B. Losartan C. Amlodipine
Answers: 1. Amlodipine 2. Losartan 3. Amlodipine Answer justification: - First-line for Black patients is CCB. - Switch ACEi to ARB if cough. - For uncontrolled BP in elderly, add CCB. Resource: NICE CKS. Hypertension. 2023.
131
MI rehabilitation advice: Mr A: 50M, uncomplicated MI with PCI — when can he drive? Mrs B: 50F, MI, heavy lifting job — when can she return to work? Mr C: 45M, MI, wants to fly 3h flight — when can he fly? Options: - 1 week - 12 weeks - 1 week
Answers: Mr A: 1 week Mrs B: 12 weeks Mr C: 1 week Answer justification: - Driving: 1 week if uncomplicated MI. - Heavy manual work: 12 weeks. - Flying: 7–10 days if stable. Resources: DVLA, BHF, CAA Guidance
132
A 38-year-old man with hypertrophic obstructive cardiomyopathy needs dental extraction. What is the SINGLE MOST appropriate advice? A. Risks of prophylaxis outweigh benefits B. See hygienist 30 mins prior C. Single dose amoxicillin 3 g pre-procedure D. 5-day course amoxicillin E. Use chlorhexidine mouthwash
Answer: A. Risks of prophylaxis outweigh benefits Answer justification: Routine antibiotic prophylaxis is not recommended for dental procedures. Resource: NICE CG64 (2008, updated 2016)
133
Which is the SINGLE MOST appropriate lipid-lowering medication for established CVD? A. Simvastatin 80 mg B. Ezetimibe 10 mg C. Simvastatin 40 mg D. Atorvastatin 20 mg E. Atorvastatin 80 mg
Answer: E. Atorvastatin 80 mg Answer justification: High-intensity statin for secondary prevention. Atorvastatin 80 mg is first-line unless contraindicated. Resource: NICE CG181 (updated 2023)
134
A 48-year-old man has palpitations. ECG shows bigeminy. What does the ECG demonstrate? A. Ventricular bigeminy B. Ventricular tachycardia C. Atrial flutter D. Second degree heart block E. Supraventricular tachycardia
Answer: A. Ventricular bigeminy Answer justification: Extrasystoles interrupt normal rhythm; wide QRS suggests ventricular origin. Compensatory pause confirms diagnosis. Resource: InnovAiT 2020
135
Clinic blood pressure targets — match each scenario: 1. 68Y hypertension 2. 71Y CKD, no proteinuria 3. 52Y T2DM, no complications 4. 28Y T1DM, ACR 75 5. 83Y hypertension 6. 43Y CKD, ACR 100
Answers: 1. 140/90 mmHg 2. 140/90 mmHg 3. 140/90 mmHg 4. 130/80 mmHg 5. 150/90 mmHg 6. 130/80 mmHg Resources: NICE NG136, NG28, NG17
136
What is the SINGLE MOST effective fourth-line drug for resistant hypertension with K+ 4.2 mmol/L? A. Spironolactone B. Methyldopa C. Doxazosin MR D. Hydralazine E. Digoxin
Answer: A. Spironolactone Answer justification: Preferred 4th-line drug if potassium ≤4.5. Use alpha/beta blocker if >4.5. Resource: NICE NG136 (2023)
137
69M, 6-week SOB on exertion. Smoker, HTN, hyperlipidaemia. Bilateral oedema to mid-shin. What is the SINGLE MOST appropriate initial investigation? A. Echocardiogram B. NT-proBNP C. Chest X-ray D. Full blood count E. Pulmonary function tests
Answer: B. NT-proBNP Answer justification: BNP is recommended initial test when HF is suspected. Resource: NICE NG106 (2018)
138
58M with 5-month SOB, orthopnoea, ankle swelling. PMH: MI 3y ago. What is the MOST appropriate initial investigation? A. Transthoracic echocardiogram B. Full blood count C. Chest x-ray D. NT-proBNP E. ECG only if AF suspected
Answer: D. NT-proBNP Answer justification: NT-proBNP is the initial test in suspected HF regardless of past MI. Resource: NICE NG106 (2018)
139
70M with 2 previous venous ulcers. Best way to prevent recurrence? A. Naftidrofuryl B. Physiotherapy C. Leg elevation D. Aspirin E. Compression hosiery
Answer: E. Compression hosiery Answer justification: Compression reduces recurrence of venous ulcers. Resource: NICE CKS. Leg ulcer – venous. 2024
140
70M with angina develops sudden, severe central abdominal pain radiating to back. HR 160, BP 80/50. What is the SINGLE MOST likely diagnosis? A. Abdominal aortic aneurysm rupture B. Biliary colic C. Mesenteric artery occlusion D. Pyelonephritis E. Ureteric colic
Answer: A. Abdominal aortic aneurysm rupture Answer justification: Pain radiating through to back + hypotension = ruptured AAA. Resource: NICE AAA Guidance
141
65M with new stable angina (Group 1 licence) asks about driving. What is the SINGLE MOST appropriate advice? A. No need to inform DVLA but must stop driving if symptoms occur at rest/emotion/driving B. Must inform DVLA and stop driving 12 months C. Inform DVLA but continue if no rest/emotion symptoms D. Inform DVLA and stop until symptoms controlled E. No need to inform DVLA and can continue driving
Answer: A. No need to inform DVLA but must stop driving if symptoms occur at rest/emotion/driving Answer justification: DVLA rules for Group 1 drivers with angina allow driving unless symptoms occur during driving, rest or emotion. Resource: DVLA Guidance; InnovAiT 2022
142
57F with aching legs, varicose veins, skin changes. What is the MOST appropriate management? A. Class I compression B. Class III compression C. Furosemide D. Refer to vascular service E. Ultrasound deep leg veins
Answer: D. Refer to vascular service Answer justification: Refer if symptomatic veins with skin changes. Do not use compression unless intervention unsuitable. Resource: NICE CG168 (2013)
143
63F, 1 year post DVT, now has swelling, pigmentation, dermatitis, lipodermatosclerosis. What is the SINGLE MOST likely diagnosis? A. Venous ulcer B. Post-thrombotic syndrome C. Cellulitis D. Recurrent DVT E. Diabetic neuropathy
Answer: B. Post-thrombotic syndrome Answer justification: Chronic condition post-DVT with swelling, pigmentation, dermatitis, lipodermatosclerosis. Resource: Allen & Wilkinson. DVT. InnovAiT 2020
144
A 66-year-old woman is starting ramipril 2.5 mg. Renal function was normal prior to commencing medication. Which of the following is the SINGLE MOST appropriate recommendation with regard to monitoring of renal function? Select ONE option only. A. Check in two days B. Check in ten days C. Check in one month D. Only recommended if the dose is increased E. Only recommended when the maximum target dose is achieved
Answer: B. Check in ten days Justification: Renal function, serum electrolytes and BP should be measured within 1–2 weeks of starting ACE inhibitors, with ongoing monitoring during titration and annually thereafter. Resource: NICE. Hypertension in adults: NG136. 2019 (updated 2022).
145
A 72-year-old man has developed leg pain worsening over 4 months, especially on walking. BP is 134/86 mmHg, cholesterol 5.7. He smokes heavily. In addition to a statin, which is the SINGLE MOST appropriate initial medication? Select ONE option only. A. Naftidifuryl B. Cilostazol C. Clopidogrel D. Rivaroxaban E. Dipyridamole
Answer: C. Clopidogrel Justification: For PAD and intermittent claudication, clopidogrel is first-line for preventing occlusive vascular events. Resources: NICE CG147 (2020); NICE TA210 (2010); BNF Clopidogrel; NICE Antiplatelet guidance (2023).
146
A 65-year-old man has LV systolic dysfunction confirmed on echo. He only uses salbutamol as needed for mild asthma. What initial therapy should he be prescribed? Select ONE option only. A. Aldosterone antagonist B. Digoxin C. Beta-blocker D. ACE inhibitor E. Angiotensin 2 receptor antagonist
Answer: D. ACE inhibitor Justification: ACE inhibitors improve symptoms and reduce mortality in systolic heart failure. Avoid beta-blockers in asthma. Resource: NICE NG106 (2018); SIGN 147.
147
A 73-year-old with heart failure has gut oedema. What is the SINGLE MOST appropriate diuretic in this case? Select ONE option only. A. Bumetanide B. Indapamide C. Furosemide D. Spironolactone E. Bendroflumethiazide
Answer: A. Bumetanide Justification: Bumetanide has better bioavailability than furosemide and is preferred in gut oedema. Resource: Thomson et al., InnovAiT 2022; 15(12): 706–711.
148
Which ONE of the DOACs can be removed with dialysis in overdose? A. Apixaban B. Dabigatran C. All DOACs D. Edoxaban E. Rivaroxaban
Answer: B. Dabigatran Justification: Dabigatran has low plasma protein binding and is dialysable. Other DOACs are not. Resource: Utomi & Draper. InnovAiT 2019; 12(4): 211–217.
149
A 42-year-old man has BP 162/94 mmHg on multiple occasions. What is the SINGLE MOST appropriate investigation? Select ONE option only. A. ABPM B. ECG C. BNP D. Urinary catecholamines E. Repeat BP over 3 weeks
Answer: A. Ambulatory blood pressure monitoring Justification: NICE recommends ABPM for confirmation of hypertension when clinic BP is 140/90 to 180/120. Resource: NICE NG136 (2019, updated 2023).
150
75-year-old woman with 4-week painful ankle ulcer. ABPI left 0.8, right 0.85. What is the SINGLE MOST likely diagnosis? A. Venous Ulcer B. Pyoderma Gangrenosum C. Arterial Ulcer D. Basal Cell Carcinoma E. Squamous Cell Carcinoma
Answer: C. Arterial Ulcer Justification: Punched out, painful ulcer with low ABPI suggests arterial origin. Resource: NICE CG147; CKS PAD
151
Using home BP monitoring to confirm diagnosis of hypertension: What is the correct protocol? A. Once daily for 3 days B. Twice daily for 3 days C. Once daily for 7 days D. Twice daily for 7 days E. Once daily for 10 days
Answer: D. Twice daily for 7 days Justification: NICE advises discarding day 1, taking readings twice daily for at least 4 and ideally 7 days. Resource: NICE NG136 (2022).
152
33-year-old woman with BP 156/94 and right loin pain. She is found to have polycystic kidney disease. What is the MOST LIKELY physical exam finding? A. Absent femoral pulse B. Radio-femoral delay C. Abdominal striae D. Renal bruit E. Ballotable kidneys
Answer: E. Ballotable kidneys Justification: Palpable kidneys suggest polycystic kidney disease in young-onset hypertension. Resource: NICE CKS; PCKD guidance.
153
57-year-old man with psoriatic arthritis (on methotrexate) has QRISK3 of 23%. Which statement is CORRECT? A. Multiply score ×1.5 if Asian B. Adjusts for social deprivation C. Includes psoriatic arthritis D. Valid age range is 35–89 years E. Predicts 5-year CHD risk
Answer: B. Adjusts for social deprivation Justification: QRISK3 includes social deprivation but not psoriatic arthritis; valid for 25–84 years; estimates 10-year CVD risk. Resource: QRISK3 documentation.
154
78-year-old woman with HTN has ankle oedema. Meds: ramipril, amlodipine, aspirin, simvastatin, lactulose. What is the SINGLE MOST helpful immediate intervention? A. Add bendroflumethiazide B. Add bumetanide C. Add furosemide D. Stop simvastatin E. Stop amlodipine
Answer: E. Stop amlodipine Justification: Amlodipine is a common cause of ankle oedema. Consider switching antihypertensive. Resource: NICE CKS; BNF Amlodipine.
155
Which is MOST likely to cause false positive NT-proBNP? A. Diabetes B. Obesity C. Hypothyroidism D. Age <60 E. African-Caribbean ethnicity
Answer: A. Diabetes Justification: Poor glycaemic control is a known non-HF cause of raised NT-proBNP. Resource: NICE NG106 (2018); BNP interpretation guides.
156
76-year-old man has brief palpitations. Ambulatory ECG confirms 2 paroxysmal AF episodes. CHA₂DS₂-VASc = 3. What SINGLE medication should be prescribed? A. Dipyridamole B. Clopidogrel C. No medication D. Apixaban E. Aspirin
Answer: D. Apixaban Justification: CHA₂DS₂-VASc ≥2 → anticoagulation. Apixaban preferred. Antiplatelets not indicated. Resource: NICE NG196 (2021).
157
66-year-old with SOB, ankle swelling, raised JVP. BNP = 2800 ng/L. What is the SINGLE MOST appropriate diagnostic investigation? A. Chest x-ray B. Coronary angiogram C. Echocardiogram D. ECG E. Exercise test
Answer: C. Echocardiogram Justification: BNP >2000 → urgent echocardiography within 2 weeks. Resource: NICE NG106 (2018).
158
73F with diabetes, asthma and IHD has new-onset AF. Irregular fast palpitations x 2 days. What is the SINGLE MOST likely underlying cause? A. Type 2 diabetes B. Alcohol C. Ischaemic heart disease D. Asthma E. Rheumatic fever
Answer: C. Ischaemic heart disease Justification: IHD is the leading cause of AF in high-income countries. Resources: Jiang et al., 2022; Sci Rep 2024; NICE NG196.
159
45M has clinic BP 150/100 on repeated readings. What is the preferred next step? A. ECG B. Echo C. Renal function D. ABPM E. Lying and standing BP
Answer: D. Ambulatory blood pressure measurement (ABPM) Justification: Clinic BP ≥140/90 should be confirmed by ABPM or HBPM. Resource: NICE NG136 (2022).
160
65M with SOB, oedema, crepitations. HR 108. BP 140/90. Which SINGLE test best supports referral for echo? A. Creatine kinase B. Cholesterol C. LDH D. Troponin E. BNP
Answer: E. BNP Justification: BNP helps triage for heart failure investigations. Resources: NICE NG106 (2018); RCGP Cardiovascular Curriculum (2019).
161
64F diagnosed with Prinzmetal angina. What is the SINGLE MOST appropriate initial treatment? A. Ramipril B. Amlodipine C. Bumetanide D. Spironolactone E. Sildenafil
Answer: B. Amlodipine Justification: Dihydropyridine CCBs like amlodipine are effective for vasospastic angina. Resource: BNF. Stable angina.
162
77F with exertional angina worsening over 2 months. On bisoprolol 10 mg. BP 155/94, HR 66. What is the most appropriate additional drug? A. Diltiazem B. Isosorbide mononitrate C. Verapamil D. Amlodipine E. Ivabradine
Answer: D. Amlodipine Justification: NICE advises adding a dihydropyridine CCB to beta-blockers if angina persists. Resource: NICE CG126 (updated 2016).
163
83F with AF is considering anticoagulation. You want to assess bleeding risk. Which tool is recommended by NICE? A. NYHA B. ABCD C. HAS-BLED D. ORBIT E. TNM
Answer: D. ORBIT Justification: NICE recommends ORBIT over HAS-BLED for bleeding risk in AF. Resource: NICE NG196 (2021).

AKT 2025 (31 decks)

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