Case 1 Questions 18-32

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Enjoy working thorugh the following questions. We hope they aid your learning. If you have any issues or feedback, please email [email protected].

Question 18

Mean Arterial Pressure is a product of cardiac output and total peripheral resistance. In which group of vessels is total peripheral resistance regulated?

  1. Aorta
  2. Veins
  3. Capillaries
  4. Arterioles
  5. Arteries

The correct answer is option d. Arterioles

Correct Answer Explanation – Correct. Resistance is determine by Poiseuille’s law, and is primarily regulated by controlling the radius of the arterioles. https://www.cvphysiology.com/Blood%20Pressure/BP006
a. Incorrect as the aorta maintains diastole blood pressure
b. Veins do not help with peripheral resistance
c. Capillaries cannot contract to maintain peripheral resistances
e. Arteries are controlling blood pressure, not peripheral resistance

Question 19

Which of the following products are NOT ‘vasodilator metabolites’

  1. ATP
  2. K+
  3. H+
  4. Lactate
  5. Adenosine

The correct answer is option a. ATP

Correct Answer Explanation – All other products are released from metabolically active tissues, and cause smooth muscle relaxation of the arterioles, increasing blood flow to the tissue. Other similar metabolites are H+ and CO2.
b. K+ increase in metabolism so will cause vasodilation
c. H+ increases in metabolism so would increase vasodilation
d. Lactate or lactic acid increases in metabolism, and cause vasodilation
e. Adenosine is produced by the breakdown of ATP, ATP itself is not a product of metabolism, as it is broken down (phosphate is cleaved off) when used in metabolically active processes.

Question 20

21 In which circumstance would baroreceptors decrease their rate of firing?

  1. Exercise
  2. Having IV fluids
  3. Sitting down from standing up
  4. In malignant hypertension
  5. Massive postpartum haemorrhage

The correct answer is option e. Massive postpartum haemorrhage

Correct Answer Explanation – Baroreceptors detect stretch of aortic and carotid vessels caused by change in arterial blood pressure. Baroreceptor stretching alters the amount of firing of nerve cells to the brain (medulla) to regulate blood pressure. Baroreceptors decrease their rate of firing in response to decreased arterial pressure. Only in D would arterial BP decrease, in all other BP would be elevated, which increases firing of the baroreceptors.
a. Incorrect as excersize would cause increased blood pressure, leading to increased baroreceptor firing
b. Havin IV fluids would increase blood pressure and baroreceptor firing
c. sitting down would increase blood pressure and baroreceptor firing
d. Malignant hypertension would mean an increased blood pressure that would cause an increase in baroreceptor firing

Question 21

The most likely presentation of carotid sinus hypersensitivity is?

  1. Falls and Syncope
  2. Palpitations
  3. Dizziness
  4. Neck Pain
  5. Sudden Cardiac Death

The correct answer is option a. Falls and Syncope

Correct Answer Explanation – Carotid sinus hypersensitivity is defined by either asystole or a significant (>50mmHg) drop in BP in response to carotid sinus massage. Aetiology is largely unknown, but is a pathological autonomic nervous reflex
b. Palpatations not commonly seen in carotid sinus hypersensitivity
c. dizziness not commonly seen in carotid sinus hypersensitivity
d. neck pain not commonly seen in carotid sinus hypersensitivity
e. sudden cardiac death not commonly seen in carotid sinus hypersensitivity

Question 22

Stage 2 hypertension is defined as which of the following:

  1. Clinic blood pressure of 160/100 mmHg or higher but less than 180/120 mmHg and subsequent ABPM daytime average or HBPM average blood pressure of 150/95 mmHg or higher.
  2. Clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg and subsequent ABPM daytime average or HBPM average blood pressure ranging from 135/85 mmHg to 149/94 mmHg.
  3. Clinic blood pressure of 160/100 mmHg or higher but less than 200/130 mmHg and subsequent ABPM daytime average or HBPM average blood pressure of 150/95 mmHg or higher.
  4. Clinic blood pressure ranging from 140/90 mmHg to 180/120 mmHg and subsequent ABPM daytime average or HBPM average blood pressure ranging from 135/85 mmHg or higher.
  5. Clinic blood pressure ranging from 160/90 mmHg to 1200/100 mmHg and subsequent ABPM daytime average or HBPM average blood pressure ranging from 155/95 mmHg or higher.

The correct answer is option a. Clinic blood pressure of 160/100 mmHg or higher but less than 180/120 mmHg and subsequent ABPM daytime average or HBPM average blood pressure of 150/95 mmHg or higher.

a is correct as stage 2 hypertension is between 160-180/100-120
b. This is Stage 1 Hypertension
c. Notice the second set of values have changed, they should be ‘but less than 180/20mmHg’ (like in A) as a clinic systolic blood pressure over 180 mmHg or clinic diastolic blood pressure over 110 mmHg would be severe hypertension!
d. Includes stage 1 and stage 2 hypertension
e. Includes stage 2 and stage 3 hypertension

Question 23

In England, it is estimated that for every 10 people diagnosed with hypertension, how many others have undiagnosed hypertension?

  1. One
  2. Ten
  3. Seven
  4. Twelve
  5. Fifteen

The correct answer is option c. Seven

Correct Answer Explanation – Correct. Hypertension is a common condition, prevalence 31% men and 26% women of all ages, is more than 50% in people aged over 60 years. Is also commonly not detected as the vast majority of patients are asymptomatic.
a. Incorrect it is 7
b. Incorrect it is seven
c. Incorrect it is seven
d. Incorrect it is seven

Question 24

QRISK3 assess the risk of? 

  1. Heart attack or stroke over the next 10 years
  2. Heart attack or stroke during the patients lifetime
  3. Heart attack or stroke over the next year
  4. Heart attack, stroke, and CKD over the next 10 years
  5. Any symptomatic cardiovascular disease over the next 10 years

The correct answer is option a. Heart attack or stroke over the next 10 years

Correct Answer Explanation – QRISK3 calculates the risk of a heart attack or stoke within the next 10 years based on various risk factors input into a complex algorithm. Commonly used in GP practice for discussions with patients around managing hypertension or starting statin therapy. https://qrisk.org/three/index.php. https://www.bmj.com/content/357/bmj.j2099
b. QRISK3 is only over 10 years, not a lifetime
c. QRISK3 is over 10 years, not a single year
d. QRISK3 does not involve CKD
e. QRISK3 also involves asymptomatic diseases

Question 25

Which investigation would NOT be required as part of calculating a QRISK3 score?

  1. ECG
  2. Lipid Profile
  3. HbA1c
  4. U&Es
  5. Full Blood Count (FBC)

The correct answer is option e. Full Blood Count (FBC)

Correct Answer Explanation – All 4 other investigations would be required to fill in sections of the QRISK score and are recommended by NICE if hypertension is diagnosed to assess for “target organ damage” as a result of hypertension. Other investigations to include a urine sample for albumin:creatinine ratio (further investigation and staging of potential CKD) and haematuria (assess for kidney damage). Also recommended to examine the optic fundi (back of eyes) for signs of hypertensive retinopathy. FBC is not required but might be suggested to assess for underlying anaemia (which can be more significant in a patient with cardiovascular disease). Other investigations to consider would be TFTs (as this can worsen cardiac disease in some cases) and LFTs (as a baseline before starting hypertension treatment)
a. ECGs are needed to see any evidence of AFib
b. Lipid profiles are needed to see the cholesterol levels
c. HbA1C is needed to check for T2DM
d. Us&Es needed to see evidence of CKD

Question 26

The term “Phaeochromocytoma” describes what?

  1. A tumour of the adrenal gland that secretes catecholamines
  2. A tumour of the pituitary gland that is non-functioning
  3. A fluctuating blood pressure, including hypertension, hypotension, and orthostatic hypotension
  4. Excess production of the hormone aldosterone from the adrenal glands
  5. Excess production of angiotensin 2 production

The correct answer is option a. A tumour of the adrenal gland that secretes catecholamines

Correct Answer Explanation – Phaeochromocytoma is a rare but important cause of secondary hypertension. Tumours, usually benign, arising from chromaffine cells in the adrenal medulla (vast majority) or elsewhere. Excess catecholamine production can cause life-threatening hypertension and/or cardiac arythmias. Present with episodes of headache, profuse sweating, palpitations and tremor with hypertension (perhaps paroxysmal) and postural hypotension. See https://rarediseases.org/rare-diseases/pheochromocytoma/ and https://patient.info/doctor/phaeochromocytoma-pro for further reading!
b. This is Non-functioning pituitary adenoma
c. Essentially a description of labile hypertension, which is feature of phaechoromocytoma
d. Primary aldosteronism – relatively common and treatable cause of secondary hypertension
e. secondary aldosteronism – less common and usually treatable and a cause of secondary hypertension

Question 27

In which scenario below would antihypertensive drug treatment be recommended to a patient by a GP?

  1. 35 year old male with clinic BP 145/90 mmHg, family history of cardiovascular disease and kidney problems
  2. 85 year old man with clinic BP 145/90 mmHg, background of stage 4 colorectal cancer and COPD
  3. 58 year old female with clinic BP 145/90 mmHg, QRISK score 8.5%, no diabetes, renal disease, or known cardiovascular disease
  4. 75 year old man with clinic BP 145/90 mmHg, history of BPH, otherwise very fit and well for his age
  5. 45 year old female with ambulatory BP 125/80 mmHg, QRISK score 6.2%, diabetes and no renal disease, or known cardiovascular disease

The correct answer is option 58 year old female with clinic BP 145/90 mmHg, QRISK score 8.5%, no diabetes, renal disease, or known cardiovascular disease. Link for further reading: https://cks.nice.org.uk/topics/hypertension-not-diabetic/management/management/

Correct Answer Explanation – Correct- although this patient has a QRISK score below 10%, as she is relatively young (<60) initiating treatment is recommended as QRISK would likely underestimate her lifelong risk of CVD.
a. Referral to specialist indicated- raised BP, young age and (perhaps) family history are suggestive of underlying secondary cause. In this case referral could be considered both for assessment of underlying cause and long-term risk vs. benefit of treatment- most common specialty is renal
b. For patients aged over 80, generally consider treatment for BP of over 150/90 mmHg only. Furthermore, in this patient with multimorbidity, a degree of judgement about the risks and benefits of treatment would be needed. Antihypertensives are aimed at prolonging life, if this is unlikely to be possible for another reason, they would be unlikely to be initiated
d. This patient may require antihypertensives, but further investigation would be required to calculate a QRISK score before considering treatment. NB: BPH is benign prostatic hyperplasia, a very common condition in elderly gentlemen.
e. Patient not hypertensive so will not need any antihypertensive medications, but should be educated on how to maintain this level

Question 28

ACE Inhibitors are the first-line management for hypertension in which patient group?

  1. Pregnant Women
  2. Caucasians aged >60 years
  3. Black-African people of any age
  4. Caucasians aged <55 years
  5. Patients with Phaeochromocytoma

The correct answer is option d. Caucasians aged <55 years

Correct Answer Explanation – Correct. ACEi are first-line for people aged <55 and not of black African or African-Caribbean family origin, and in hypertension with T2DM. Link to nice visual summary: https://www.nice.org.uk/guidance/ng136/resources/visual-summary-pdf-6899919517
a. Incorrect, ACE inhibitors are contraindicated in pregnant women
b. Incorrect, first-line in this case is a CCB
c. Incorrect as for B
e. Incorrect as they will need secondary referral

Question 29

In which clinical scenario would it be most appropriate to prescribe an ARB?

  1. ACE inhibitor fails to control BP adequately therefore ARB is added
  2. Patient experienced hyperkalaemia after taking ACE inhibitor
  3. Patient experienced a dry cough after 6 months on ACE inhibitor
  4. Patient with a background of diabetes mellitus and currently taking aliskerin has poorly controlled BP
  5. Patients taking a CCB which does not adequately control the hypertension

The correct answer is option c. Patient experienced a dry cough after 6 months on ACE inhibitor

Correct Answer Explanation – Correct. If patient experiences a cough when taking ACEi, this is troublesome, and other causes have been excluded, consider switching patient to an ARB
a. Incorrect. Combinations of ACEi and ARBs should be avoided unless essential, and if so should be managed in secondary care
b. Incorrect. Hyperkalaemia should when taking an ACEi or ARB be managed in the same way, there is no role for switching from one drug to another
d. Incorrect. Aliskerin is a direct renin inhibitor, should not be used alongside other drugs that act on the RAAS without specialist advice, and combination of aliskerin with ACEi or ARBs is contraindicated in patients with DM or and eGFR<60
e. After a CCB a ACE inhibitor should be prescribed, not a ARB, unless a dry cough is complained about after having the ACE inhibitor

Question 30

Which Calcium Channel Blocker would a patient with hypertension be most likely to receive?

  1. Amlodipine
  2. Verapamil hydrochloride
  3. Nicardipine hydrochloride
  4. Diltiazem
  5. Aliskerin

The correct answer is option a. Amlodipine

Correct Answer Explanation – Commonly prescribed for hypertension. Causes vasodilation without cardiac depressant effect. Additional information: CCBs bind to and block the L-type calcium channel, primarily found in the myocardium and vascular smooth muscle. CCBs are divided into classes based on their effects. Dihydropyridines (e.g. amlodipine, other drugs with suffix –dipine) are potent vasodilators with minimal effect on the heart. Non-dihydropyridine CCBs have more potent myocardial depressant effects
b. Verapamil- more commonly used to manage arrythmias, angina, and hypertension
c. Nicardipine – unlikely to be used in routine practice as must be taken 3x daily
d. Diltiazem – similarly to verapamil, more commonly used for angina, less myocardial depression than verapamil
e. Aliskerin is not a calcium channel blocker but a renin inhibitor

Question 31

What is the drug class and mechanism of action in hypertension of Indapamide?

  1. Loop Diuretic, diuresis
  2. Thiazide-like diuretic, diuresis
  3. Thiazide diuretic, diuresis
  4. Thiazide diuretic, vasodilation
  5. Thiazide-like diuretic, vasodilation

The correct answer is option e. Thiazide-like diuretic, vasodilation

Correct Answer Explanation – Correct. Indapamide is a thiazide like-diuretic recommended as a second or third line management for hypertension. At low doses, as used in hypertension, thiazide-like diuretics have more prominent vasodilation actions, diuretic effects only become more apparent at higher doses. Other thiazide like diuretics include chlortalidone. Additional information: Bendroflumethiazide is a thiazide diuretic, It is no longer recommended as first-line for hypertension but patients can remain taking it if they are stable on treatment. Most commonly used to treat oedema in heart failure. Examples of loop diuretics include furosemide, not currently recommended by NICE for hypertension. Link for further reading: https://bnf.nice.org.uk/treatment-summary/diuretics.html
a. Indiapamide is not a loop diuretic, but a thiazide-like diuretic
b. Indiapamide uses vasodilation, not diuresis in controlling hypertension
c. Indiapamide is not a thiazide diuretic, but a thiazide-like diuretic
e. Indiapamide is not a thiazide diuretic, but a thiazide-like diuretic

Question 32

Which of the following conditions might cause significant differences in BP readings between each arm?

  1. Coarctation of the descending aorta
  2. Stanford Type A Aortic Dissection
  3. Myocardial Infarction
  4. Pre-Eclampsia
  5. Pulmonary embolism

The correct answer is option b. Stanford Type A Aortic Dissection

Correct Answer Explanation – Correct. L/R BP differential is a classic feature of Aortic Dissection. This is where there is damage to the inner wall of the aorta and so blood can move between the layers of that aortic wall forcing them apart. In Type A, the damage is in the ascending aorta before the subclavian arteries so can alter the blood pressure in each arm. Additional information: Aortic dissection classically presents with tearing chest pain, radiating to the back. However the presentation may be more non-specific, with signs of hypovolaemic shock and new aortic regurgitation. Type A dissections must involve the ascending aorta carry a high mortality rate and require urgent specialist surgical management. Type B aortic dissections are typically managed medically with strict BP control and close monitoring. See https://www.intechopen.com/books/differential-diagnosis-of-chest-pain/aortic-dissection, BMJ Best Practice and https://teachmesurgery.com/vascular/arterial/aortic-dissection/ for further reading!
a. Incorrect. Coarctation at the descending aorta would cause differences in BP between the upper and lower extremities, as well as diminished pulses in the lower limbs. It would not cause differences in the arms as the narrowing would be at a point lower than the subclavian arteries which are the branches of the aorta which supply the arms.
c. Incorrect
d. Incorrect – Pre-Eclampsia refers to new-onset hypertension in pregnancy, alongside new-onset proteinuria (most cases) or other signs and symptoms
e. Incorrect – Pulmonary hypertension is typically a sign of Left sided heart faliure and can lead to SOB but not. a difference in blood pressures on each arm