Cardiovascular & Respiratory

A 58-year-old man presents with 40 minutes of crushing central chest pain. His ECG shows ST elevation in leads II, III and aVF. Which coronary territory is most likely affected?

• ALateral wall, usually the left circumflex artery
• BInferior wall, usually the right coronary artery✓
• CPosterior wall, seen as ST depression in V1 to V3
• DAnterior wall, usually the left anterior descending artery

Answer: Leads II, III and aVF look at the inferior surface of the heart, which is supplied by the right coronary artery in most people. Anterior infarcts show in V1 to V4, lateral in I, aVL, V5 and V6, and posterior infarcts appear as reciprocal ST depression in the anterior leads.

A 48-year-old woman of white European origin has a clinic blood pressure of 162/100 mmHg confirmed by ambulatory monitoring. She has no diabetes. According to NICE, which drug should be started first?

• AA thiazide-like diuretic such as indapamide
• BAn ACE inhibitor such as ramipril✓
• CA beta-blocker such as bisoprolol
• DA calcium-channel blocker such as amlodipine

Answer: NICE recommends an ACE inhibitor (or an ARB if not tolerated) as the first step for people under 55 who are not of Black African or African-Caribbean family origin. A calcium-channel blocker is first-line for people who do not have type 2 diabetes and are either aged 55 and over or of Black African or African-Caribbean family origin at any age.

A 24-year-old with asthma attends A&E breathless. She cannot complete sentences, her respiratory rate is 28, pulse 118, and peak flow is 40% of her predicted value. How should this attack be classified?

• AAcute severe asthma✓
• BModerate asthma exacerbation
• CNear-fatal asthma
• DLife-threatening asthma

Answer: Acute severe asthma is defined by any of: peak flow 33 to 50% of best or predicted, respiratory rate of 25 or more, heart rate of 110 or more, or inability to complete sentences in one breath. Life-threatening features would include peak flow below 33%, oxygen saturation below 92%, a silent chest, cyanosis or altered consciousness.

A 70-year-old man with known COPD is admitted with an exacerbation. His oxygen saturation is 86% on air. What target saturation range should be set while awaiting a blood gas?

• A96 to 100%
• B80 to 85%
• C88 to 92%✓
• D94 to 98%

Answer: Patients at risk of hypercapnic respiratory failure, including many with COPD, are given controlled oxygen to a target of 88 to 92% until a blood gas shows whether they retain carbon dioxide. 94 to 98% is the target for most other acutely ill adults.

A 72-year-old woman with community-acquired pneumonia is confused, has a respiratory rate of 32 and a urea of 9 mmol/L; her blood pressure is 118/76. What is her CURB-65 score?

• A4✓
• B3
• C2
• D5

Answer: CURB-65 gives one point each for Confusion, Urea above 7 mmol/L, Respiratory rate of 30 or more, Blood pressure below 90 systolic or 60 or below diastolic, and age 65 or over. She scores for confusion, urea, respiratory rate and age but not blood pressure: 4, indicating severe pneumonia needing hospital admission.

A 35-year-old woman develops pleuritic chest pain and breathlessness ten days after a long-haul flight. Her heart rate is 104 and she has a swollen left calf. What is the most appropriate initial imaging?

• ACT pulmonary angiogram✓
• BChest X-ray alone
• CVentilation-perfusion scan
• DEchocardiogram

Answer: With a likely pulmonary embolism (two-level Wells score above 4 given clinical signs of DVT and tachycardia), NICE recommends immediate CT pulmonary angiography, with interim anticoagulation if it cannot be done straight away. A V/Q scan is reserved for people who cannot have a CTPA, such as those with contrast allergy or renal impairment.

A 66-year-old man with heart failure and a left ventricular ejection fraction of 30% is breathless on minimal exertion. Which combination is the recommended first-line disease-modifying treatment?

• AAn ACE inhibitor and a beta-blocker licensed for heart failure✓
• BA calcium-channel blocker and a nitrate
• CA loop diuretic and digoxin, titrated to control the symptoms of congestion
• DAn antiplatelet and a statin alone

Answer: For heart failure with reduced ejection fraction, NICE recommends an ACE inhibitor (or ARB) together with a beta-blocker licensed for heart failure as first-line treatment, because both improve survival. Loop diuretics relieve congestion but do not change prognosis, and rate-limiting calcium-channel blockers can worsen heart failure.

A 78-year-old woman with newly diagnosed atrial fibrillation has hypertension and had a transient ischaemic attack last year. What is the most important treatment to reduce her stroke risk?

• AAspirin 75 mg daily
• BCardioversion as soon as possible
• CAnticoagulation with a direct oral anticoagulant✓
• DRate control with bisoprolol alone

Answer: Her CHA₂DS₂-VASc score is high (age, sex, hypertension and prior TIA), so anticoagulation is indicated, and NICE recommends a DOAC such as apixaban as first choice. Aspirin is not recommended for stroke prevention in AF, and rate control alone does not reduce stroke risk.

A 55-year-old man has crushing chest pain and an ECG showing ST elevation in V1 to V4. He is 30 minutes from a primary PCI centre. What is the definitive treatment?

• AOral aspirin alone and discharge with cardiology clinic follow-up in two weeks
• BThrombolysis with streptokinase on the ward, since it is quicker to give than transferring him for PCI
• CPrimary percutaneous coronary intervention within 120 minutes of the time fibrinolysis could have been given✓
• DSublingual GTN, oxygen and observation on the coronary care unit

Answer: Primary PCI is the treatment of choice for STEMI when it can be delivered within 120 minutes of the time fibrinolysis could have been given; fibrinolysis is used only when PCI cannot be provided in time.

A 60-year-old man is breathless with bilateral crackles, a raised JVP and pink frothy sputum after an MI. What is the first-line treatment?

• AA rapid infusion of one litre of normal saline to support the circulation, followed by a second litre if the blood pressure falls
• BAn oral beta-blocker at a high dose to reduce the work of the heart and slow the pulse
• CIntravenous antibiotics for pneumonia, since crackles and frothy sputum indicate infection
• DIntravenous furosemide with oxygen, sitting the patient upright, and nitrates if blood pressure allows✓

Answer: Acute pulmonary oedema is treated with an intravenous loop diuretic, oxygen if hypoxic, and intravenous nitrates can be considered here because of the concomitant myocardial ischaemia (NICE does not recommend them routinely in acute heart failure); fluids would worsen it, and beta-blockers are withheld during acute decompensation.

A 30-year-old woman with a history of asthma develops wheeze and breathlessness. Her oxygen saturation is 89% and she is drowsy. How should this be classified and managed?

• AAnaphylaxis — intramuscular adrenaline 500 micrograms, repeated after five minutes if there is no response
• BModerate asthma — inhaled salbutamol via a spacer, oral prednisolone and discharge with a written asthma action plan and GP follow-up within two days
• CLife-threatening asthma — call for senior help, give oxygen to keep saturations at 94 to 98%, nebulised salbutamol with ipratropium, and intravenous hydrocortisone✓
• DAcute severe asthma — oral prednisolone, nebulised salbutamol and review in an hour, with admission only if she does not improve

Answer: Oxygen saturation below 92% and altered consciousness are life-threatening features requiring immediate senior involvement and intensive treatment; exhaustion and a silent chest are further warning signs.

A 45-year-old man is found to have a blood pressure of 190/120 mmHg with retinal haemorrhages and papilloedema. What is the diagnosis?

• AAccelerated (malignant) hypertension requiring same-day specialist assessment✓
• BWhite-coat hypertension, which needs ambulatory monitoring before any treatment is considered
• CNormal blood pressure for his age, needing no action beyond a repeat in a year
• DStage 1 hypertension needing lifestyle advice and a repeat clinic reading in three months

Answer: Blood pressure above 180/120 with signs of end-organ damage such as retinal haemorrhages or papilloedema is accelerated hypertension, which needs same-day specialist assessment and controlled reduction of blood pressure.