A 71-year-old woman is admitted with acute decompensated heart failure. She has known heart failure with LVEF 34% and is usually managed on ramipril 10 mg, bisoprolol 7.5 mg, spironolactone 25 mg, and furosemide 80 mg daily. On admission: BP 96/58 mmHg, HR 68 bpm, oxygen saturation 90% on air. She has pulmonary crepitations and peripheral oedema. Bloods show: Na+ 128 mmol/L, K+ 5.3 mmol/L, urea 18.2 mmol/L, creatinine 168 μmol/L (baseline 110 μmol/L). What is the most appropriate immediate management?
Q52
A 65-year-old man presents to the Emergency Department with sudden onset severe central chest pain radiating to the back, which started 3 hours ago. He has a history of hypertension and Marfan syndrome. On examination, blood pressure is 168/92 mmHg in the right arm and 142/86 mmHg in the left arm. Heart rate is 98 bpm. There is an early diastolic murmur at the left sternal edge. ECG shows sinus rhythm with left ventricular hypertrophy but no acute ischaemic changes. What is the most appropriate immediate investigation?
Q53
A 43-year-old woman attends for cardiovascular risk assessment. She is asymptomatic. Her father had a myocardial infarction at age 48. She is a non-smoker. Blood pressure is 128/78 mmHg, BMI 24 kg/m². Lipid profile shows: total cholesterol 8.2 mmol/L, LDL cholesterol 5.8 mmol/L, HDL cholesterol 1.3 mmol/L, triglycerides 2.1 mmol/L. Her QRISK3 score is calculated as 12%. Physical examination reveals bilateral Achilles tendon xanthomata. What is the most appropriate next step?
Q54
A 69-year-old man presents with progressive breathlessness over 6 months. He can now only walk 50 meters on the flat before stopping due to dyspnoea. He has paroxysmal atrial fibrillation and hypertension. Echocardiography shows left ventricular ejection fraction of 58%, left ventricular hypertrophy, left atrial dilatation, and E/e' ratio of 16. NT-proBNP is 580 pg/mL. What is the most appropriate initial pharmacological management?
Q55
A 52-year-old woman presents with 3 months of exertional chest tightness that occurs predictably when walking uphill and is relieved by rest within 5 minutes. She has a family history of ischaemic heart disease (father had myocardial infarction aged 54). She is a non-smoker with well-controlled hypertension. CT coronary angiography shows 60% stenosis of the proximal left anterior descending artery with no other significant disease. Fractional flow reserve (FFR) is 0.84. She is already taking aspirin, atorvastatin, and amlodipine. What is the most appropriate management of her angina?
Q56
A 78-year-old woman with permanent atrial fibrillation is reviewed in the anticoagulation clinic. She has a history of hypertension, type 2 diabetes, and previous ischaemic stroke 2 years ago. She is currently taking warfarin but has had multiple INR measurements outside therapeutic range despite good compliance. Her most recent INR results over 8 weeks show values of 1.8, 3.6, 2.1, 3.8, and 1.9 (target 2.0-3.0). She has normal renal function (eGFR 68 mL/min/1.73m²) and no history of bleeding. What is the most appropriate management?
Q57
A 49-year-old man presents to the Emergency Department with 2 hours of central crushing chest pain at rest. He has a history of hypertension and is a current smoker. Initial ECG shows sinus rhythm with 1 mm ST-segment depression in leads V4-V6. His high-sensitivity troponin I at presentation is 8 ng/L (normal <16 ng/L). Observations: BP 152/88 mmHg, heart rate 78 bpm, oxygen saturation 97% on air. He is given aspirin 300 mg, ticagrelor 180 mg, and sublingual GTN. What is the most appropriate next step in management?
Q58
A 57-year-old man with chronic heart failure due to dilated cardiomyopathy (LVEF 32%) is reviewed in the heart failure clinic. He is currently taking ramipril 10 mg once daily, bisoprolol 10 mg once daily, spironolactone 25 mg once daily, and furosemide 40 mg once daily. He remains breathless on minimal exertion (NYHA class III). His ECG shows sinus rhythm with QRS duration of 156 ms and left bundle branch block morphology. Blood pressure is 118/76 mmHg. Renal function and electrolytes are normal. What is the most appropriate next step in management?
Q59
A 61-year-old woman attends her GP surgery for a routine health check. She has no symptoms and no significant past medical history. Clinic blood pressure measurement is 148/94 mmHg. On repeat measurement 5 minutes later, it is 146/92 mmHg. Physical examination is unremarkable. She is a non-smoker with BMI 26 kg/m². What is the most appropriate next step in management?
Q60
A 66-year-old woman with permanent atrial fibrillation presents with progressive fatigue and dyspnoea over 6 months. She takes apixaban 5 mg twice daily and no rate-control medication. Her heart rate is irregularly irregular at 115-130 bpm at rest, blood pressure 118/76 mmHg. Echocardiography shows normal left ventricular systolic function (LVEF 58%), mild left atrial dilatement, and no significant valvular disease. NT-proBNP is 420 ng/L (mildly elevated). She has failed previous trials of bisoprolol due to fatigue and diltiazem due to peripheral oedema. What is the most appropriate next pharmacological management for rate control?
Cardiology UK Medical PG Practice Questions and MCQs
Question 51: A 71-year-old woman is admitted with acute decompensated heart failure. She has known heart failure with LVEF 34% and is usually managed on ramipril 10 mg, bisoprolol 7.5 mg, spironolactone 25 mg, and furosemide 80 mg daily. On admission: BP 96/58 mmHg, HR 68 bpm, oxygen saturation 90% on air. She has pulmonary crepitations and peripheral oedema. Bloods show: Na+ 128 mmol/L, K+ 5.3 mmol/L, urea 18.2 mmol/L, creatinine 168 μmol/L (baseline 110 μmol/L). What is the most appropriate immediate management?
A. Increase furosemide to 160 mg daily and withhold ACE inhibitor and spironolactone (Correct Answer)
B. Start intravenous dobutamine infusion
C. Give intravenous furosemide bolus and continue all regular medications
D. Start intravenous furosemide and withhold ACE inhibitor, continue other medications
E. Start ultrafiltration therapy
Explanation: ***Increase furosemide to 160 mg daily and withhold ACE inhibitor and spironolactone***
- The patient presents with **acute decompensated heart failure** complicated by **volume overload**, **acute kidney injury (AKI)**, and **hyperkalaemia** (K+ 5.3 mmol/L), indicating cardiorenal syndrome.
- Increasing **furosemide** helps alleviate fluid overload, while temporarily stopping **ramipril** (ACE inhibitor) and **spironolactone** (MRA) is crucial to prevent further worsening of AKI and hyperkalaemia, which are critical in this acute setting.
*Start intravenous dobutamine infusion*
- **Dobutamine**, an inotrope, is typically reserved for patients with severe **cardiogenic shock** or profound hypoperfusion, which is not clearly evident despite borderline hypotension (BP 96/58 mmHg).
- Administering an inotrope without clear indications of shock can increase myocardial oxygen demand and risk of **arrhythmias** in a stable, although decompensated, patient.
*Give intravenous furosemide bolus and continue all regular medications*
- Continuing **ramipril** and **spironolactone** is contraindicated given the patient's **acute kidney injury** (creatinine 168 μmol/L) and **hyperkalaemia** (K+ 5.3 mmol/L).
- This approach would exacerbate renal dysfunction and potentially lead to life-threatening hyperkalaemia.
*Start intravenous furosemide and withhold ACE inhibitor, continue other medications*
- While withholding the **ACE inhibitor** is appropriate, continuing **spironolactone** (a potassium-sparing diuretic) is inappropriate in the presence of **hyperkalaemia** (K+ 5.3 mmol/L) and rising **creatinine**.
- Both the ACE inhibitor and the mineralocorticoid receptor antagonist contribute to hyperkalaemia and can worsen renal function, thus both should be withheld.
*Start ultrafiltration therapy*
- **Ultrafiltration** is an advanced therapy typically considered for patients with **refractory volume overload** or severe **diuretic resistance** despite high-dose loop diuretics.
- It is not an initial management step before maximizing and assessing the response to aggressive pharmacological diuresis.
Question 52: A 65-year-old man presents to the Emergency Department with sudden onset severe central chest pain radiating to the back, which started 3 hours ago. He has a history of hypertension and Marfan syndrome. On examination, blood pressure is 168/92 mmHg in the right arm and 142/86 mmHg in the left arm. Heart rate is 98 bpm. There is an early diastolic murmur at the left sternal edge. ECG shows sinus rhythm with left ventricular hypertrophy but no acute ischaemic changes. What is the most appropriate immediate investigation?
A. Transthoracic echocardiography
B. High-sensitivity troponin
C. CT aortic angiography (Correct Answer)
D. Chest X-ray
E. Coronary angiography
Explanation: ***CT aortic angiography***- This is the **gold standard** for diagnosing **acute aortic dissection** due to its high sensitivity and specificity, allowing for rapid assessment of the dissection flap and its extent.- In this patient, risk factors like **Marfan syndrome**, hypertension, and clinical signs such as a **blood pressure differential** and **aortic regurgitation** (early diastolic murmur) make this the definitive first-line test.*Transthoracic echocardiography*- While useful at the bedside for screening **pericardial effusion** or measuring the aortic root, it lacks the sensitivity to reliably exclude aortic dissection.- **Transoesophageal echocardiography** is much more accurate but is more invasive and often less readily available than CT.*High-sensitivity troponin*- While commonly performed for chest pain, it is **non-specific** and may be elevated in aortic dissection if the dissection affects the coronary arteries.- Relying on this marker can cause a **dangerous delay** in diagnosing a life-threatening dissection when the history strongly suggests a vascular catastrophe.*Chest X-ray*- It may demonstrate a **widened mediastinum** or an abnormal aortic contour, but up to 20% of patients with dissection have a normal X-ray.- This investigation lacks enough **sensitivity and specificity** to be used as a standalone tool for ruling out dissection.*Coronary angiography*- This is primarily used for **myocardial infarction** and is generally **contraindicated** if aortic dissection is suspected because the catheter could enter the false lumen and worsen the tear.- The ECG here shows **left ventricular hypertrophy** but no ST-segment changes, making a primary coronary event less likely than a dissection.
Question 53: A 43-year-old woman attends for cardiovascular risk assessment. She is asymptomatic. Her father had a myocardial infarction at age 48. She is a non-smoker. Blood pressure is 128/78 mmHg, BMI 24 kg/m². Lipid profile shows: total cholesterol 8.2 mmol/L, LDL cholesterol 5.8 mmol/L, HDL cholesterol 1.3 mmol/L, triglycerides 2.1 mmol/L. Her QRISK3 score is calculated as 12%. Physical examination reveals bilateral Achilles tendon xanthomata. What is the most appropriate next step?
A. Start atorvastatin 20 mg once daily
B. Provide lifestyle advice and reassess in 12 months
C. Start atorvastatin 80 mg once daily
D. Arrange CT coronary angiography
E. Refer to lipid clinic for assessment of familial hypercholesterolaemia (Correct Answer)
Explanation: ***Refer to lipid clinic for assessment of familial hypercholesterolaemia***
- This patient presents with classical features of **Familial Hypercholesterolaemia (FH)**, including a very high **LDL cholesterol (5.8 mmol/L)**, a strong **family history of premature coronary artery disease**, and the pathognomonic finding of **bilateral Achilles tendon xanthomata**.
- **FH** is a genetic condition requiring urgent specialist assessment, genetic confirmation, and **cascade screening** of family members, as standard risk calculators like QRISK3 underestimate the true risk.
*Start atorvastatin 20 mg once daily*
- While statins are indicated, **atorvastatin 20 mg** is a low-intensity dose, which is generally insufficient for managing the severe hypercholesterolaemia seen in **Familial Hypercholesterolaemia (FH)**.
- The initial management of suspected FH involves **specialist referral** for diagnosis and genetic testing, rather than immediate initiation of a potentially inadequate dose of statin.
*Provide lifestyle advice and reassess in 12 months*
- **Lifestyle modifications** alone are inadequate for achieving significant reductions in cholesterol levels in **Familial Hypercholesterolaemia (FH)**, which is a genetic disorder.
- Delaying treatment for 12 months in a patient with a very high **LDL cholesterol**, strong family history, and **tendon xanthomata** would expose her to continued high risk of **premature cardiovascular events**.
*Start atorvastatin 80 mg once daily*
- **Atorvastatin 80 mg** is a high-intensity statin appropriate for the aggressive management of **Familial Hypercholesterolaemia (FH)**.
- However, the most appropriate *next step* is to confirm the diagnosis of FH via a **lipid clinic referral** to ensure comprehensive management, genetic testing, and family screening, which precedes or is done in conjunction with initiating high-dose therapy.
*Arrange CT coronary angiography*
- **CT coronary angiography** is typically used to assess for **coronary artery disease** in symptomatic patients or for reclassification of risk in certain high-risk asymptomatic individuals.
- For this asymptomatic patient, the immediate priority is to diagnose and manage her probable **Familial Hypercholesterolaemia**, not to screen for existing anatomical lesions.
Question 54: A 69-year-old man presents with progressive breathlessness over 6 months. He can now only walk 50 meters on the flat before stopping due to dyspnoea. He has paroxysmal atrial fibrillation and hypertension. Echocardiography shows left ventricular ejection fraction of 58%, left ventricular hypertrophy, left atrial dilatation, and E/e' ratio of 16. NT-proBNP is 580 pg/mL. What is the most appropriate initial pharmacological management?
A. Start ramipril and bisoprolol (Correct Answer)
B. Start spironolactone and furosemide
C. Start furosemide alone
D. Start sacubitril-valsartan
E. Start digoxin and furosemide
Explanation: ***Start ramipril and bisoprolol***- This patient presents with clear signs of **Heart Failure with preserved Ejection Fraction (HFpEF)**, characterized by **normal LVEF (58%)**, **LV hypertrophy**, **LA dilatation**, and **elevated E/e' ratio**, in the context of **dyspnoea** and elevated **NT-proBNP**.- **Ramipril (an ACE inhibitor)** is crucial for managing his **hypertension** and mitigating **LV remodeling**, which is central to HFpEF management. **Bisoprolol (a beta-blocker)** is essential for **rate control** in his **paroxysmal atrial fibrillation** and also helps manage hypertension, improving diastolic filling.*Start spironolactone and furosemide*- While **spironolactone (an MRA)** can be beneficial in HFpEF by reducing fibrosis and improving diastolic function, it's typically considered after optimizing blood pressure and heart rate, and often used to reduce hospitalizations rather than as *initial* management for all aspects.- **Furosemide (a loop diuretic)** will alleviate **symptomatic congestion** and breathlessness, but it does not address the underlying **hypertension** or the need for **rate control** in atrial fibrillation, which are critical initial steps.*Start furosemide alone*- **Furosemide** provides effective **symptomatic relief** from congestion and dyspnoea by reducing fluid overload.- However, monotherapy with a diuretic does not manage the patient's **hypertension**, control his **atrial fibrillation rate**, or offer **prognostic benefits** in HFpEF, making it an incomplete initial management strategy.*Start sacubitril-valsartan*- **Sacubitril-valsartan (an ARNI)** is primarily indicated for patients with **Heart Failure with reduced Ejection Fraction (HFrEF)** to improve mortality and reduce hospitalizations.- Although there is some emerging evidence for its use in HFpEF, particularly in a subset, it is generally not considered the **initial pharmacological management** for a newly diagnosed HFpEF patient with uncontrolled hypertension and AF.*Start digoxin and furosemide*- **Digoxin** is used for **rate control** in atrial fibrillation, especially if other agents like beta-blockers are contraindicated or ineffective, but it has a narrow therapeutic index and does not address **hypertension** or **LV hypertrophy**.- This combination lacks the comprehensive approach to manage the patient's **hypertension**, which is a key driver of his HFpEF, and does not provide the robust benefits of ACE inhibitors or beta-blockers in this context.
Question 55: A 52-year-old woman presents with 3 months of exertional chest tightness that occurs predictably when walking uphill and is relieved by rest within 5 minutes. She has a family history of ischaemic heart disease (father had myocardial infarction aged 54). She is a non-smoker with well-controlled hypertension. CT coronary angiography shows 60% stenosis of the proximal left anterior descending artery with no other significant disease. Fractional flow reserve (FFR) is 0.84. She is already taking aspirin, atorvastatin, and amlodipine. What is the most appropriate management of her angina?
A. Add ivabradine and continue medical management
B. Add bisoprolol and continue medical management (Correct Answer)
C. Refer for percutaneous coronary intervention to LAD
D. Add isosorbide mononitrate and continue medical management
E. Refer for coronary artery bypass grafting
Explanation: ***Add bisoprolol and continue medical management***
- **Beta-blockers** like **bisoprolol** are first-line pharmacological agents for managing symptoms of stable angina, especially when a patient is already on a calcium channel blocker like amlodipine.
- The **Fractional Flow Reserve (FFR) of 0.84** indicates that the 60% LAD stenosis is not hemodynamically significant (threshold for significance is generally <0.80), thus favoring **optimal medical therapy** over revascularization.
*Add ivabradine and continue medical management*
- **Ivabradine** is a second-line anti-anginal agent, typically used if **beta-blockers** are contraindicated, not tolerated, or if angina is uncontrolled despite optimal doses of first-line agents, in patients in sinus rhythm with a heart rate ≥70 bpm.
- Since beta-blockers haven't been tried in this patient, they should be prioritized before considering **ivabradine**.
*Refer for percutaneous coronary intervention to LAD*
- **Percutaneous coronary intervention (PCI)** is not indicated in this case because the **FFR of 0.84** confirms that the 60% stenosis is not causing **myocardial ischemia** and is not hemodynamically significant.
- Revascularization of lesions with an FFR >0.80 has not shown benefit over **optimal medical therapy** in improving clinical outcomes for stable angina.
*Add isosorbide mononitrate and continue medical management*
- **Long-acting nitrates** like **isosorbide mononitrate** are generally considered second-line agents for angina symptom relief.
- They are typically added if symptoms persist despite **beta-blockers** and/or calcium channel blockers, or if these first-line agents are contraindicated or not tolerated.
*Refer for coronary artery bypass grafting*
- **Coronary artery bypass grafting (CABG)** is a major surgical procedure reserved for patients with extensive coronary artery disease, such as **left main stem disease** or **multi-vessel disease**, or complex lesions not suitable for PCI.
- This patient has single-vessel disease (LAD) that is not physiologically significant (FFR >0.80), making CABG an inappropriate and overly invasive option.
Question 56: A 78-year-old woman with permanent atrial fibrillation is reviewed in the anticoagulation clinic. She has a history of hypertension, type 2 diabetes, and previous ischaemic stroke 2 years ago. She is currently taking warfarin but has had multiple INR measurements outside therapeutic range despite good compliance. Her most recent INR results over 8 weeks show values of 1.8, 3.6, 2.1, 3.8, and 1.9 (target 2.0-3.0). She has normal renal function (eGFR 68 mL/min/1.73m²) and no history of bleeding. What is the most appropriate management?
A. Switch to apixaban 5 mg twice daily (Correct Answer)
B. Continue warfarin and add aspirin 75 mg once daily
C. Continue warfarin and review INR weekly
D. Switch to aspirin 75 mg once daily and clopidogrel 75 mg once daily
E. Switch to dabigatran 110 mg twice daily
Explanation: ***Switch to apixaban 5 mg twice daily***- In patients with **atrial fibrillation** and poor **INR control** (time in therapeutic range < 65%), NICE guidelines recommend switching to a **direct oral anticoagulant (DOAC)**.- A dose of 5 mg twice daily is correct as she does not meet the criteria for **dose reduction** (age ≥ 80, weight ≤ 60 kg, or creatinine ≥ 133 μmol/L).*Continue warfarin and add aspirin 75 mg once daily*- Adding **aspirin** to warfarin does not improve stroke prevention in AF and significantly increases the **risk of major bleeding**.- This patient already demonstrates **labile INRs**, making the addition of antiplatelets even more dangerous without addressing the underlying anticoagulation instability.*Continue warfarin and review INR weekly*- The patient has had multiple measurements outside the **therapeutic range (2.0-3.0)** despite good compliance, indicating that warfarin is unsuitable for her long-term management.- Continuing current therapy fails to address the high **thromboembolic risk** (CHA2DS2-VASc score of 7) associated with sub-therapeutic INR levels.*Switch to aspirin 75 mg once daily and clopidogrel 75 mg once daily*- **Dual antiplatelet therapy (DAPT)** is significantly less effective than anticoagulation for stroke prevention in AF.- Given the patient's high risk profile (age, diabetes, stroke history), DAPT offers **suboptimal protection** against ischaemic events.*Switch to dabigatran 110 mg twice daily*- While switching to a DOAC is correct, the 110 mg dose of **dabigatran** is typically reserved for patients aged **80 or older** or those at high risk of bleeding.- As this patient is 78 years old and has a normal **eGFR of 68**, the standard dose (150 mg) or an alternative DOAC like **apixaban** is more appropriate.
Question 57: A 49-year-old man presents to the Emergency Department with 2 hours of central crushing chest pain at rest. He has a history of hypertension and is a current smoker. Initial ECG shows sinus rhythm with 1 mm ST-segment depression in leads V4-V6. His high-sensitivity troponin I at presentation is 8 ng/L (normal <16 ng/L). Observations: BP 152/88 mmHg, heart rate 78 bpm, oxygen saturation 97% on air. He is given aspirin 300 mg, ticagrelor 180 mg, and sublingual GTN. What is the most appropriate next step in management?
A. Discharge with outpatient cardiology follow-up
B. Arrange immediate coronary angiography
C. Start fondaparinux and arrange angiography within 72 hours
D. Repeat high-sensitivity troponin at 3 hours from symptom onset (Correct Answer)
E. Observe for 6 hours and repeat troponin before discharge
Explanation: ***Repeat high-sensitivity troponin at 3 hours from symptom onset***
- The patient presents with classic symptoms of **Acute Coronary Syndrome (ACS)** and ischemic **ECG changes (ST-depression)**. However, the initial **high-sensitivity troponin (hs-cTn)** was taken only 2 hours after pain onset, which may be too early to detect a significant rise.
- Guidelines (e.g., ESC 0/1h or 0/3h protocols) recommend serial troponin testing to detect a dynamic **rise or fall** in levels, which is crucial for differentiating **NSTEMI** from unstable angina or non-cardiac chest pain.
*Discharge with outpatient cardiology follow-up*
- This option is unsafe as the patient has **active chest pain** and **ischemic ECG changes (ST-segment depression)**, indicating a high probability of ACS.
- Discharge is only appropriate if serial troponin measurements are definitively negative and the patient is deemed **low-risk** after comprehensive assessment.
*Arrange immediate coronary angiography*
- Immediate angiography (within 2 hours) is reserved for **ST-elevation myocardial infarction (STEMI)** or **very high-risk NSTE-ACS** (e.g., hemodynamic instability, refractory angina, life-threatening arrhythmias, mechanical complications).
- This patient is currently hemodynamically stable, making immediate angiography premature before confirming myocardial injury with serial troponins.
*Start fondaparinux and arrange angiography within 72 hours*
- While **fondaparinux** and inpatient angiography are standard for confirmed intermediate-to-high-risk **NSTE-ACS**, the diagnosis must first be established with serial troponins.
- Initiating full anticoagulation without confirming myocardial infarction via a dynamic troponin change or a high-risk score is premature at this diagnostic stage.
*Observe for 6 hours and repeat troponin before discharge*
- With the advent of **high-sensitivity troponin assays**, the diagnostic window for rule-in/rule-out of MI has significantly shortened.
- Waiting 6 hours for a repeat troponin is an outdated practice for hs-cTn, as current guidelines recommend much shorter intervals (e.g., 0/1h or 0/3h) for more rapid and efficient diagnosis.
Question 58: A 57-year-old man with chronic heart failure due to dilated cardiomyopathy (LVEF 32%) is reviewed in the heart failure clinic. He is currently taking ramipril 10 mg once daily, bisoprolol 10 mg once daily, spironolactone 25 mg once daily, and furosemide 40 mg once daily. He remains breathless on minimal exertion (NYHA class III). His ECG shows sinus rhythm with QRS duration of 156 ms and left bundle branch block morphology. Blood pressure is 118/76 mmHg. Renal function and electrolytes are normal. What is the most appropriate next step in management?
A. Increase furosemide to 80 mg once daily
B. Increase spironolactone to 50 mg once daily
C. Refer for cardiac resynchronisation therapy assessment (Correct Answer)
D. Add ivabradine 5 mg twice daily
E. Add digoxin 125 mcg once daily
Explanation: ***Refer for cardiac resynchronisation therapy assessment***
- This patient meets the criteria for **Cardiac Resynchronisation Therapy (CRT)** due to **symptomatic heart failure (NYHA Class III)** with **reduced ejection fraction (LVEF 32%)**, **optimal medical therapy**, and a **wide QRS duration (156 ms)** with **Left Bundle Branch Block (LBBB)** morphology.
- CRT improves **ventricular synchrony**, leading to enhanced cardiac output and significant reductions in **morbidity and mortality** in appropriately selected patients.
*Increase furosemide to 80 mg once daily*
- **Furosemide**, a loop diuretic, provides **symptomatic relief** from congestion but does not offer prognostic benefits or address the underlying **cardiac dyssynchrony**.
- There are no specific signs of worsening **fluid overload** (e.g., increased weight, peripheral edema, pulmonary crackles) presented in the vignette to prioritize an increased diuretic dose as the next step.
*Increase spironolactone to 50 mg once daily*
- The patient is already on a **guideline-recommended dose of spironolactone (25 mg)**, which provides most of the mortality benefit from **mineralocorticoid receptor antagonism**.
- Increasing the dose would not address the **electrical dyssynchrony** indicated by the wide QRS and LBBB, and could increase the risk of **hyperkalemia**.
*Add ivabradine 5 mg twice daily*
- **Ivabradine** is indicated for symptomatic **HFrEF patients** in **sinus rhythm** with a resting **heart rate ≥70-75 bpm** despite maximal beta-blocker therapy.
- The patient's heart rate is not provided, and even if elevated, addressing the **QRS widening and LBBB** with CRT takes precedence given the strong evidence for its benefit.
*Add digoxin 125 mcg once daily*
- **Digoxin** is typically used for **rate control in atrial fibrillation** or as an adjunctive therapy for **symptomatic HFrEF** that remains refractory to other guideline-directed medical and device therapies, without a mortality benefit.
- It does not address the **electromechanical dyssynchrony** present and is not the first-line intervention when clear indications for **CRT** exist.
Question 59: A 61-year-old woman attends her GP surgery for a routine health check. She has no symptoms and no significant past medical history. Clinic blood pressure measurement is 148/94 mmHg. On repeat measurement 5 minutes later, it is 146/92 mmHg. Physical examination is unremarkable. She is a non-smoker with BMI 26 kg/m². What is the most appropriate next step in management?
A. Start amlodipine 5 mg once daily
B. Arrange 24-hour urine collection for metanephrines
C. Arrange ambulatory blood pressure monitoring (Correct Answer)
D. Start ramipril 2.5 mg once daily
E. Repeat clinic blood pressure measurement in 1 month
Explanation: ***Arrange ambulatory blood pressure monitoring***
- For a patient with a clinic blood pressure between **140/90 mmHg and 179/120 mmHg**, the next step under **NICE guidelines** is to offer **Ambulatory Blood Pressure Monitoring (ABPM)** or Home Blood Pressure Monitoring (HBPM) to confirm the diagnosis.
- This step is essential to rule out **white coat hypertension** and accurately categorize the patient's blood pressure stage before initiating long-term therapy.
*Start amlodipine 5 mg once daily*
- Initiating **antihypertensive medication** such as a Calcium Channel Blocker is premature without a confirmed diagnosis through ABPM or HBPM.
- Pharmacotherapy is generally only started immediately for **Stage 2 hypertension** (clinic BP >160/100) with end-organ damage or **Stage 3 hypertension** (>180/120).
*Arrange 24-hour urine collection for metanephrines*
- Screening for **secondary causes** like **pheochromocytoma** is not indicated as the patient is asymptomatic and does not have resistant or paroxysmal hypertension.
- Initial focus must remain on confirming **essential hypertension** through standardized monitoring protocols.
*Start ramipril 2.5 mg once daily*
- Starting an **ACE inhibitor** without diagnostic confirmation is incorrect and bypasses necessary risk assessment and staging protocols.
- Even if diagnosed, the choice of first-line agent depends on **age** and **ethnicity**, which follows confirmation of persistent high blood pressure.
*Repeat clinic blood pressure measurement in 1 month*
- Simply repeating **clinic measurements** is insufficient for diagnosis and lacks the accuracy of out-of-office monitoring required by modern guidelines.
- Waiting one month may delay necessary intervention if the patient truly has **hypertension**, whereas ABPM provides a definitive average over a 24-hour period.
Question 60: A 66-year-old woman with permanent atrial fibrillation presents with progressive fatigue and dyspnoea over 6 months. She takes apixaban 5 mg twice daily and no rate-control medication. Her heart rate is irregularly irregular at 115-130 bpm at rest, blood pressure 118/76 mmHg. Echocardiography shows normal left ventricular systolic function (LVEF 58%), mild left atrial dilatement, and no significant valvular disease. NT-proBNP is 420 ng/L (mildly elevated). She has failed previous trials of bisoprolol due to fatigue and diltiazem due to peripheral oedema. What is the most appropriate next pharmacological management for rate control?
A. Commence amiodarone 200 mg once daily for rhythm control
B. Commence digoxin 125 mcg once daily (Correct Answer)
C. Arrange urgent DC cardioversion
D. Commence verapamil 80 mg three times daily
E. Refer for AV node ablation and permanent pacemaker insertion
Explanation: ***Commence digoxin 125 mcg once daily***
- **Digoxin** is the most appropriate next step for **rate control** in permanent AF when first-line agents like **beta-blockers** and **calcium channel blockers** are contraindicated or not tolerated, as is the case for this patient.
- It primarily works by increasing **vagal tone** on the **AV node** to reduce the ventricular rate, especially at rest, and does not have the fatigue or peripheral oedema side effects observed with the previously failed medications.
*Commence amiodarone 200 mg once daily for rhythm control*
- This patient has **permanent atrial fibrillation**, meaning the goal of management is **rate control**, not rhythm control.
- **Amiodarone** is an antiarrhythmic typically used for **rhythm control**, and its long-term use is associated with significant **extracardiac toxicities** (e.g., pulmonary, thyroid, hepatic), making it unsuitable for routine rate control.
*Arrange urgent DC cardioversion*
- **DC cardioversion** is a procedure for **rhythm control**, typically indicated for hemodynamically unstable AF or for restoring sinus rhythm in symptomatic, non-permanent AF.
- Given that the patient has **permanent AF** and is **hemodynamically stable**, cardioversion is not an appropriate intervention for her chronic symptoms.
*Commence verapamil 80 mg three times daily*
- **Verapamil** is a **non-dihydropyridine calcium channel blocker**, pharmacologically similar to **diltiazem**, which the patient previously failed due to **peripheral oedema**.
- There is a high probability of **cross-intolerance** and recurrence of similar adverse effects, making it an unsuitable alternative in this clinical scenario.
*Refer for AV node ablation and permanent pacemaker insertion*
- **AV node ablation with pacemaker implantation** is an invasive, **last-resort strategy** for rate control in AF, considered only when all optimal pharmacological options have been exhausted and symptoms remain refractory.
- This option is premature, as the patient has not yet tried **digoxin**, which is a viable pharmacological alternative for rate control.
