Next

Question 1 of 44

A 67-year-old man is discharged after having a percutaneous coronary intervention following an

acute coronary syndrome (ACS). He had no past medical of note prior to the ACS. Which type of
lipid modification therapy should he have been started on during the admission?
A. Simvastatin 40mg on
B. Atorvastatin 10mg on
C. Atorvastatin 20mg on
D. Atorvastatin 40mg on
E. Atorvastatin 80mg on
Next question

Patients with established CVD should take atorvastatin 80mg on

Hyperlipidaemia: management
In 2014 NICE updated their guidelines on lipid modification. This proved highly controversial as it
meant that we should be recommending statins to a significant proportion of the population over the
age of 60 years. Anyway, the key points of the new guidelines are summarised below.

Primary prevention - who and how to assess risk

A systematic strategy should be used to identify people aged over 40 years who are likely to be at
high risk of cardiovascular disease (CVD), defined as a 10-year risk of 10% or greater.
NICE recommend we use the QRISK2 CVD risk assessment tool for patients aged <= 84 years.
Patients >= 85 years are at high risk of CVD due to their age. QRISK2 should not be used in the
following situations as there are more specific guidelines for these patient groups:

type 1 diabetics

patients with an estimated glomerular filtration rate (eGFR) less than 60 ml/min and/or
albuminuria
patients with a history of familial hyperlipidaemia

NICE suggest QRISK2 may underestimate CVD risk in the following population groups:

people treated for HIV

people with serious mental health problems

people taking medicines that can cause dyslipidaemia such as antipsychotics, corticosteroids
or immunosuppressant drugs

people with autoimmune disorders/systemic inflammatory disorders such as systemic lupus

erythematosus

Measuring lipid levels

When measuring lipids both the total cholesterol and HDL should be checking to provide the most
accurate risk of CVD. A full lipid profile should also be checked (i.e. including triglycerides) before
starting a statin. The samples does not need to be fasting.
In the vast majority of patient the cholesterol measurements will be fed into the QRISK2 tool. If
however the patient's cholesterol is very high we should consider familial hyperlipidaemia. NICE
recommend the following that we should consider the possibility of familial hypercholesterolaemia
and investigate further if the total cholesterol concentration is > 7.5 mmol/l and there is a family
history of premature coronary heart disease. They also recommend referring people with a total
cholesterol > 9.0 mmol/l or a non-HDL cholesterol (i.e. LDL) of > 7.5 mmol/l even in the absence of a
first-degree family history of premature coronary heart disease.

Interpreting the QRISK2 result

Probably the headline changes in the 2014 guidelines was the new, lower cut-off of 10-year CVD
risk cut-off of 10%.
NICE now recommend we offer a statin to people with a QRISK2 10-year risk of >= 10%
Lifestyle factors are of course important and NICE recommend that we give patients the option of
having their CVD risk reassessed after a period of time before starting a statin.

Atorvastatin 20mg should be offered first-line.

Special situations
Type 1 diabetes mellitus

NICE recommend that we 'consider statin treatment for the primary prevention of CVD in all
adults with type 1 diabetes'
atorvastatin 20 mg should be offered if type 1 diabetics who are:
older than 40 years, or
have had diabetes for more than 10 years or
have established nephropathy or
have other CVD risk factors

Chronic kidney disease (CKD)

atorvastatin 20mg should be offered to patients with CKD

increase the dose if a greater than 40% reduction in non-HDL cholesterol is not achieved
and the eGFR > 30 ml/min. If the eGFR is < 30 ml/min a renal specialist should be consulted
before increasing the dose

Secondary prevention
All patients with CVD should be taking a statin in the absence of any contraindication.
Atorvastatin 80mg should be offered first-line.

Follow-up of people started on statins

NICE recommend we follow-up patients at 3 months

repeat a full lipid profile

if the non-HDL cholesterol has not fallen by at least 40% concordance and lifestyle changes
should be discussed with the patient
NICE recommend we consider increasing the dose of atorvastatin up to 80mg

Lifestyle modifications
These are in many ways predictable but NICE make a number of specific points:
Cardioprotective diet

total fat intake should be <= 30% of total energy intake

saturated fats should be <= 7% of total energy intake
intake of dietary cholesterol should be < 300 mg/day
saturated fats should be replaced by monounsaturated and polyunsaturated fats where
possible
replace saturated and monounsaturated fat intake with olive oil, rapeseed oil or spreads
based on these oils
choose wholegrain varieties of starchy food
reduce their intake of sugar and food products containing refined sugars including fructose
eat at least 5 portions of fruit and vegetables per day
eat at least 2 portions of fish per week, including a portion of oily fish
eat at least 4 to 5 portions of unsalted nuts, seeds and legumes per week

Physical activity

each week aim for at least 150 minutes of moderate intensity aerobic activity or 75 minutes
of vigorous intensity aerobic activity or a mix of moderate and vigorous aerobic activity
do musclestrengthening activities on 2 or more days a week that work all major muscle
groups (legs, hips, back, abdomen, chest, shoulders and arms) in line with national guidance
for the general population

Weight management

no specific advice is given, overweight patients should be managed in keeping with relevant
NICE guidance

Alcohol intake

again no specific advice, other than the general recommendation that males drink no more
than 3-4 units/day and females no more than 2-3 units/day

Smoking cessation

smokers should be encouraged to quit

Question 2 of 44

Next

You are review a 38-year-old woman with type 1 diabetes mellitus in clinic. Her diabetes is currently
controlled with a basal-bolus regime. She takes no other medication apart from citalopram 20mg od
for depression. She was diagnosed with type 1 diabetes at the age of 13 years. Her most recent
bloods show

Na+
142 mmol/l
+
K
3.9 mmol/l
Urea
4.9 mmol/l
Creatinine 79 mol/l

Total cholesterol 4.4 mmol/l

HDL cholesterol 1.2 mmol/l
LDL cholesterol 1.8 mmol/l
Triglyceride
1.3 mmol/l
Urine dip: No protein or blood
What is the most appropriate management with regards to lipid modification?
A. Start atorvastatin 10mg on
B. Start atorvastatin 20mg on
C. Start atorvastatin 40mg on
D. Perform a QRISK2 assessment
E. Reassure her that lipid modification therapy is not required at this stage
Next question

NICE specifically state that we should not use QRISK2 for type 1 diabetics. Instead, the following
criteria are used:

older than 40 years, or

have had diabetes for more than 10 years or
have established nephropathy or
have other CVD risk factors

This patient has had diabetes for 25 years so we should start atorvastatin 20mg on.
Hyperlipidaemia: management
In 2014 NICE updated their guidelines on lipid modification. This proved highly controversial as it
meant that we should be recommending statins to a significant proportion of the population over the
age of 60 years. Anyway, the key points of the new guidelines are summarised below.

Primary prevention - who and how to assess risk

A systematic strategy should be used to identify people aged over 40 years who are likely to be at
high risk of cardiovascular disease (CVD), defined as a 10-year risk of 10% or greater.
NICE recommend we use the QRISK2 CVD risk assessment tool for patients aged <= 84 years.
Patients >= 85 years are at high risk of CVD due to their age. QRISK2 should not be used in the
following situations as there are more specific guidelines for these patient groups:

type 1 diabetics
patients with an estimated glomerular filtration rate (eGFR) less than 60 ml/min and/or
albuminuria
patients with a history of familial hyperlipidaemia

NICE suggest QRISK2 may underestimate CVD risk in the following population groups:

people treated for HIV

people with serious mental health problems
people taking medicines that can cause dyslipidaemia such as antipsychotics, corticosteroids
or immunosuppressant drugs

people with autoimmune disorders/systemic inflammatory disorders such as systemic lupus

erythematosus

Measuring lipid levels

When measuring lipids both the total cholesterol and HDL should be checking to provide the most
accurate risk of CVD. A full lipid profile should also be checked (i.e. including triglycerides) before
starting a statin. The samples does not need to be fasting.
In the vast majority of patient the cholesterol measurements will be fed into the QRISK2 tool. If
however the patient's cholesterol is very high we should consider familial hyperlipidaemia. NICE
recommend the following that we should consider the possibility of familial hypercholesterolaemia
and investigate further if the total cholesterol concentration is > 7.5 mmol/l and there is a family
history of premature coronary heart disease. They also recommend referring people with a total
cholesterol > 9.0 mmol/l or a non-HDL cholesterol (i.e. LDL) of > 7.5 mmol/l even in the absence of a
first-degree family history of premature coronary heart disease.

Interpreting the QRISK2 result

Probably the headline changes in the 2014 guidelines was the new, lower cut-off of 10-year CVD
risk cut-off of 10%.
NICE now recommend we offer a statin to people with a QRISK2 10-year risk of >= 10%
Lifestyle factors are of course important and NICE recommend that we give patients the option of
having their CVD risk reassessed after a period of time before starting a statin.
Atorvastatin 20mg should be offered first-line.

Special situations
Type 1 diabetes mellitus

NICE recommend that we 'consider statin treatment for the primary prevention of CVD in all
adults with type 1 diabetes'
atorvastatin 20 mg should be offered if type 1 diabetics who are:
older than 40 years, or

have had diabetes for more than 10 years or

have established nephropathy or
have other CVD risk factors

Chronic kidney disease (CKD)

atorvastatin 20mg should be offered to patients with CKD

increase the dose if a greater than 40% reduction in non-HDL cholesterol is not achieved
and the eGFR > 30 ml/min. If the eGFR is < 30 ml/min a renal specialist should be consulted
before increasing the dose

Secondary prevention
All patients with CVD should be taking a statin in the absence of any contraindication.
Atorvastatin 80mg should be offered first-line.

Follow-up of people started on statins

NICE recommend we follow-up patients at 3 months

repeat a full lipid profile

if the non-HDL cholesterol has not fallen by at least 40% concordance and lifestyle changes
should be discussed with the patient
NICE recommend we consider increasing the dose of atorvastatin up to 80mg

Lifestyle modifications
These are in many ways predictable but NICE make a number of specific points:
Cardioprotective diet

total fat intake should be <= 30% of total energy intake

saturated fats should be <= 7% of total energy intake
intake of dietary cholesterol should be < 300 mg/day
saturated fats should be replaced by monounsaturated and polyunsaturated fats where
possible

replace saturated and monounsaturated fat intake with olive oil, rapeseed oil or spreads
based on these oils
choose wholegrain varieties of starchy food
reduce their intake of sugar and food products containing refined sugars including fructose
eat at least 5 portions of fruit and vegetables per day
eat at least 2 portions of fish per week, including a portion of oily fish
eat at least 4 to 5 portions of unsalted nuts, seeds and legumes per week

Physical activity

each week aim for at least 150 minutes of moderate intensity aerobic activity or 75 minutes
of vigorous intensity aerobic activity or a mix of moderate and vigorous aerobic activity
do musclestrengthening activities on 2 or more days a week that work all major muscle
groups (legs, hips, back, abdomen, chest, shoulders and arms) in line with national guidance
for the general population

Weight management

no specific advice is given, overweight patients should be managed in keeping with relevant
NICE guidance

Alcohol intake

again no specific advice, other than the general recommendation that males drink no more
than 3-4 units/day and females no more than 2-3 units/day

Smoking cessation

smokers should be encouraged to quit

Question 3 of 44

Next

A 49-year-old man comes into clinic. One of his friends has recently had a myocardial infarction and
he is concerned about his own risk of coronary heart disease. He has no past medical history of note

other than anxiety for which he is not currently taking any medication. He does however smoker
around 20 cigarettes a day. Cardiovascular examination is unremarkable. His BMI is 26 kg/m and
blood pressure is 126/82 mmHg.
You strongly advise him to stop smoking. What is the most appropriate further course of action?
A. Reassure him that he has a very low risk of coronary heart disease given his
age
B. Arrange a 24 hour blood pressure monitor
C. Arrange a lipid profile then calculate his QRISK2 score
D. Start orlistat
E. Refer him for an exercise tolerance test
Next question
If we feed his age, gender and smoking history into QRISK2 this gives a 10-year-risk of
cardiovascular disease (CVD) of 13.9%. He is therefore an appropriate person to have a 'formal'
assessment of CVD risk using a lipid profile to further inform the QRISK2 score.
Hyperlipidaemia: management
In 2014 NICE updated their guidelines on lipid modification. This proved highly controversial as it
meant that we should be recommending statins to a significant proportion of the population over the
age of 60 years. Anyway, the key points of the new guidelines are summarised below.

Primary prevention - who and how to assess risk

A systematic strategy should be used to identify people aged over 40 years who are likely to be at
high risk of cardiovascular disease (CVD), defined as a 10-year risk of 10% or greater.
NICE recommend we use the QRISK2 CVD risk assessment tool for patients aged <= 84 years.
Patients >= 85 years are at high risk of CVD due to their age. QRISK2 should not be used in the
following situations as there are more specific guidelines for these patient groups:

type 1 diabetics
patients with an estimated glomerular filtration rate (eGFR) less than 60 ml/min and/or
albuminuria

patients with a history of familial hyperlipidaemia

NICE suggest QRISK2 may underestimate CVD risk in the following population groups:

people treated for HIV

people with serious mental health problems
people taking medicines that can cause dyslipidaemia such as antipsychotics, corticosteroids
or immunosuppressant drugs
people with autoimmune disorders/systemic inflammatory disorders such as systemic lupus
erythematosus

Measuring lipid levels

When measuring lipids both the total cholesterol and HDL should be checking to provide the most
accurate risk of CVD. A full lipid profile should also be checked (i.e. including triglycerides) before
starting a statin. The samples does not need to be fasting.
In the vast majority of patient the cholesterol measurements will be fed into the QRISK2 tool. If
however the patient's cholesterol is very high we should consider familial hyperlipidaemia. NICE
recommend the following that we should consider the possibility of familial hypercholesterolaemia
and investigate further if the total cholesterol concentration is > 7.5 mmol/l and there is a family
history of premature coronary heart disease. They also recommend referring people with a total
cholesterol > 9.0 mmol/l or a non-HDL cholesterol (i.e. LDL) of > 7.5 mmol/l even in the absence of a
first-degree family history of premature coronary heart disease.

Interpreting the QRISK2 result

Probably the headline changes in the 2014 guidelines was the new, lower cut-off of 10-year CVD
risk cut-off of 10%.
NICE now recommend we offer a statin to people with a QRISK2 10-year risk of >= 10%
Lifestyle factors are of course important and NICE recommend that we give patients the option of
having their CVD risk reassessed after a period of time before starting a statin.
Atorvastatin 20mg should be offered first-line.

Special situations
Type 1 diabetes mellitus

NICE recommend that we 'consider statin treatment for the primary prevention of CVD in all
adults with type 1 diabetes'
atorvastatin 20 mg should be offered if type 1 diabetics who are:
older than 40 years, or
have had diabetes for more than 10 years or
have established nephropathy or
have other CVD risk factors

Chronic kidney disease (CKD)

atorvastatin 20mg should be offered to patients with CKD

increase the dose if a greater than 40% reduction in non-HDL cholesterol is not achieved
and the eGFR > 30 ml/min. If the eGFR is < 30 ml/min a renal specialist should be consulted
before increasing the dose

Secondary prevention
All patients with CVD should be taking a statin in the absence of any contraindication.
Atorvastatin 80mg should be offered first-line.

Follow-up of people started on statins

NICE recommend we follow-up patients at 3 months

repeat a full lipid profile

if the non-HDL cholesterol has not fallen by at least 40% concordance and lifestyle changes
should be discussed with the patient
NICE recommend we consider increasing the dose of atorvastatin up to 80mg

Lifestyle modifications
These are in many ways predictable but NICE make a number of specific points:

Cardioprotective diet

total fat intake should be <= 30% of total energy intake

saturated fats should be <= 7% of total energy intake
intake of dietary cholesterol should be < 300 mg/day
saturated fats should be replaced by monounsaturated and polyunsaturated fats where
possible
replace saturated and monounsaturated fat intake with olive oil, rapeseed oil or spreads
based on these oils
choose wholegrain varieties of starchy food
reduce their intake of sugar and food products containing refined sugars including fructose
eat at least 5 portions of fruit and vegetables per day
eat at least 2 portions of fish per week, including a portion of oily fish
eat at least 4 to 5 portions of unsalted nuts, seeds and legumes per week

Physical activity

each week aim for at least 150 minutes of moderate intensity aerobic activity or 75 minutes
of vigorous intensity aerobic activity or a mix of moderate and vigorous aerobic activity
do musclestrengthening activities on 2 or more days a week that work all major muscle
groups (legs, hips, back, abdomen, chest, shoulders and arms) in line with national guidance
for the general population

Weight management

no specific advice is given, overweight patients should be managed in keeping with relevant
NICE guidance

Alcohol intake

again no specific advice, other than the general recommendation that males drink no more
than 3-4 units/day and females no more than 2-3 units/day

Smoking cessation

smokers should be encouraged to quit

3/3

Next

Question 4-6 of 44

Theme: Vitamin deficiency

A. Vitamin A
B. Thiamine
C. Niacin
D. Pyridoxine
E. Folic acid
F. Vitamin B12
G. Vitamin C
H. Vitamin D
I. Vitamin E
J. Vitamin K
For each one of the following scenarios select the vitamin which may cause these features if
deficient:

4.

Bleeding gums
Vitamin C

5.

Diarrhoea, confusion and eczematous skin

Niacin
This is pellagra

6.

Osteomalacia
Vitamin D

Next question

Vitamin deficiency

The table below summarises vitamin deficiency states

Vitamin

Chemical name

Deficiency state

Retinoids

Night-blindness (nyctalopia)

B1

Thiamine

Beriberi

B3

Niacin

polyneuropathy, Wernicke-Korsakoff syndrome

heart failure

Pellagra

dermatitis
diarrhoea
dementia

B6

Pyridoxine

Anaemia, irritability, seizures

B7

Biotin

Dermatitis, seborrhoea

B9

Folic acid

Megaloblastic anaemia, deficiency during pregnancy - neural tube defects

B12

Cyanocobalamin

Megaloblastic anaemia, peripheral neuropathy

Ascorbic acid

Scurvy

gingivitis
bleeding

Ergocalciferol,
cholecalciferol

Rickets, osteomalacia

Tocopherol, tocotrienol

Mild haemolytic anaemia in newborn infants, ataxia, peripheral

neuropathy

Naphthoquinone

Haemorrhagic disease of the newborn, bleeding diathesis

Next

Question 7 of 44
A 60-year-old man is found to have a QRISK2 score of 14% after having his cholesterol levels
checked. After discussing the pros and cons he elects to start atorvastatin 20mg on.

Total cholesterol 5.6 mmol/l

HDL cholesterol 1.0 mmol/l
LDL cholesterol 3.4 mmol/l
Triglyceride
1.7 mmol/l
At what point should he have a repeat cholesterol test done to test the effectiveness of the statin?
A. 6 weeks
B. 12 weeks
C. 6 months
D. 12 months
E. Checking cholesterol levels is not needed in primary prevention
Next question

A lipid profile and liver function tests should be performed 3 months after starting a statin

NICE recommend the following:

Measure total cholesterol, HDL cholesterol and non-HDL cholesterol in all people who have been
started on high-intensity statin treatment at 3 months of treatment and aim for a greater than 40%
reduction in non-HDL cholesterol.

Hyperlipidaemia: management
In 2014 NICE updated their guidelines on lipid modification. This proved highly controversial as it
meant that we should be recommending statins to a significant proportion of the population over the

age of 60 years. Anyway, the key points of the new guidelines are summarised below.

Primary prevention - who and how to assess risk

A systematic strategy should be used to identify people aged over 40 years who are likely to be at
high risk of cardiovascular disease (CVD), defined as a 10-year risk of 10% or greater.
NICE recommend we use the QRISK2 CVD risk assessment tool for patients aged <= 84 years.
Patients >= 85 years are at high risk of CVD due to their age. QRISK2 should not be used in the
following situations as there are more specific guidelines for these patient groups:

type 1 diabetics
patients with an estimated glomerular filtration rate (eGFR) less than 60 ml/min and/or
albuminuria
patients with a history of familial hyperlipidaemia

NICE suggest QRISK2 may underestimate CVD risk in the following population groups:

people treated for HIV

people with serious mental health problems
people taking medicines that can cause dyslipidaemia such as antipsychotics, corticosteroids
or immunosuppressant drugs
people with autoimmune disorders/systemic inflammatory disorders such as systemic lupus
erythematosus

Measuring lipid levels

When measuring lipids both the total cholesterol and HDL should be checking to provide the most
accurate risk of CVD. A full lipid profile should also be checked (i.e. including triglycerides) before
starting a statin. The samples does not need to be fasting.
In the vast majority of patient the cholesterol measurements will be fed into the QRISK2 tool. If
however the patient's cholesterol is very high we should consider familial hyperlipidaemia. NICE
recommend the following that we should consider the possibility of familial hypercholesterolaemia
and investigate further if the total cholesterol concentration is > 7.5 mmol/l and there is a family
history of premature coronary heart disease. They also recommend referring people with a total
cholesterol > 9.0 mmol/l or a non-HDL cholesterol (i.e. LDL) of > 7.5 mmol/l even in the absence of a

first-degree family history of premature coronary heart disease.

Interpreting the QRISK2 result

Probably the headline changes in the 2014 guidelines was the new, lower cut-off of 10-year CVD
risk cut-off of 10%.
NICE now recommend we offer a statin to people with a QRISK2 10-year risk of >= 10%
Lifestyle factors are of course important and NICE recommend that we give patients the option of
having their CVD risk reassessed after a period of time before starting a statin.
Atorvastatin 20mg should be offered first-line.

Special situations
Type 1 diabetes mellitus

NICE recommend that we 'consider statin treatment for the primary prevention of CVD in all
adults with type 1 diabetes'
atorvastatin 20 mg should be offered if type 1 diabetics who are:
older than 40 years, or
have had diabetes for more than 10 years or
have established nephropathy or
have other CVD risk factors

Chronic kidney disease (CKD)

atorvastatin 20mg should be offered to patients with CKD

increase the dose if a greater than 40% reduction in non-HDL cholesterol is not achieved
and the eGFR > 30 ml/min. If the eGFR is < 30 ml/min a renal specialist should be consulted
before increasing the dose

Secondary prevention
All patients with CVD should be taking a statin in the absence of any contraindication.

Atorvastatin 80mg should be offered first-line.

Follow-up of people started on statins

NICE recommend we follow-up patients at 3 months

repeat a full lipid profile

if the non-HDL cholesterol has not fallen by at least 40% concordance and lifestyle changes
should be discussed with the patient
NICE recommend we consider increasing the dose of atorvastatin up to 80mg

Lifestyle modifications
These are in many ways predictable but NICE make a number of specific points:
Cardioprotective diet

total fat intake should be <= 30% of total energy intake

saturated fats should be <= 7% of total energy intake
intake of dietary cholesterol should be < 300 mg/day
saturated fats should be replaced by monounsaturated and polyunsaturated fats where
possible
replace saturated and monounsaturated fat intake with olive oil, rapeseed oil or spreads
based on these oils
choose wholegrain varieties of starchy food
reduce their intake of sugar and food products containing refined sugars including fructose
eat at least 5 portions of fruit and vegetables per day
eat at least 2 portions of fish per week, including a portion of oily fish
eat at least 4 to 5 portions of unsalted nuts, seeds and legumes per week

Physical activity

each week aim for at least 150 minutes of moderate intensity aerobic activity or 75 minutes
of vigorous intensity aerobic activity or a mix of moderate and vigorous aerobic activity
do musclestrengthening activities on 2 or more days a week that work all major muscle
groups (legs, hips, back, abdomen, chest, shoulders and arms) in line with national guidance
for the general population

Weight management

no specific advice is given, overweight patients should be managed in keeping with relevant
NICE guidance

Alcohol intake

again no specific advice, other than the general recommendation that males drink no more
than 3-4 units/day and females no more than 2-3 units/day

Smoking cessation

smokers should be encouraged to quit

Question 8 of 44

Next

You are reviewing a patient's blood results:

K+

6.2 mmol/l

Which one of the following medications is most likely to be responsible for this result?
A. Sodium bicarbonate
B. Bendroflumethiazide
C. Frusemide
D. Spironolactone
E. St John's Wort
Next question

Hyperkalaemia
Plasma potassium levels are regulated by a number of factors including aldosterone, acid-base
balance and insulin levels. Metabolic acidosis is associated with hyperkalaemia as hydrogen and
potassium ions compete with each other for exchange with sodium ions across cell membranes and
in the distal tubule. ECG changes seen in hyperkalaemia include tall-tented T waves, small P waves,
widened QRS leading to a sinusoidal pattern and asystole
Causes of hyperkalaemia:

acute renal failure

drugs*: potassium sparing diuretics, ACE inhibitors, angiotensin 2 receptor blockers,
spironolactone, ciclosporin, heparin**
metabolic acidosis
Addison's
rhabdomyolysis
massive blood transfusion

Foods that are high in potassium:

salt substitutes (i.e. Contain potassium rather than sodium)

bananas, oranges, kiwi fruit, avocado, spinach, tomatoes

*beta-blockers interfere with potassium transport into cells and can potentially cause hyperkalaemia
in renal failure patients - remember beta-agonists, e.g. Salbutamol, are sometimes used as
emergency treatment
**both unfractionated and low-molecular weight heparin can cause hyperkalaemia. This is thought to
be caused by inhibition of aldosterone secretion

Question 9 of 44
A 35-year-old woman presents concerned about her weight. Her body mass index is 34 kg/m^2.
Which one of the following best describes her weight?

Next

A. Obese (Obese I)
B. Morbidly obese (Obese III)
C. Overweight
D. Clinically obese (Obese II)
E. Normal
Next question

Body mass index

Body mass index (BMI) is calculated by dividing the weight (in kilograms) by the height (in metres)
squared

BMI

Old classification NICE classification

< 18.5

Underweight

Underweight

18.5 - 24.9

Normal

Normal

25 - 29.9

Overweight

Overweight

30 - 34.9

Obese

Obese I

35 - 39.9

Clinically obese

Obese II

> 40

Morbidly obese

Obese III

Question 10 of 44

Next

Which one of the following statements regarding NICE guidance on the primary prevention of
cardiovascular disease (CVD) is correct
A. Premature coronary heart disease is defined as < 75 years in females
B. A 10-year risk of 20% is used to identify patients who should be considered
for lipid-lowering therapy
C. Atorvastatin 40mg on is the first line treatment in patients with a significant
risk
D. QRISK2 should be used in preference to the Joint British Society 2 (JBS2) risk
tool
E. QRISK2 can be used for a patient who is 88-years-old
Next question

Hyperlipidaemia: management
In 2014 NICE updated their guidelines on lipid modification. This proved highly controversial as it
meant that we should be recommending statins to a significant proportion of the population over the
age of 60 years. Anyway, the key points of the new guidelines are summarised below.

Primary prevention - who and how to assess risk

A systematic strategy should be used to identify people aged over 40 years who are likely to be at
high risk of cardiovascular disease (CVD), defined as a 10-year risk of 10% or greater.
NICE recommend we use the QRISK2 CVD risk assessment tool for patients aged <= 84 years.
Patients >= 85 years are at high risk of CVD due to their age. QRISK2 should not be used in the
following situations as there are more specific guidelines for these patient groups:

type 1 diabetics
patients with an estimated glomerular filtration rate (eGFR) less than 60 ml/min and/or
albuminuria
patients with a history of familial hyperlipidaemia

NICE suggest QRISK2 may underestimate CVD risk in the following population groups:

people treated for HIV

people with serious mental health problems
people taking medicines that can cause dyslipidaemia such as antipsychotics, corticosteroids
or immunosuppressant drugs
people with autoimmune disorders/systemic inflammatory disorders such as systemic lupus
erythematosus

Measuring lipid levels

When measuring lipids both the total cholesterol and HDL should be checking to provide the most
accurate risk of CVD. A full lipid profile should also be checked (i.e. including triglycerides) before
starting a statin. The samples does not need to be fasting.
In the vast majority of patient the cholesterol measurements will be fed into the QRISK2 tool. If
however the patient's cholesterol is very high we should consider familial hyperlipidaemia. NICE
recommend the following that we should consider the possibility of familial hypercholesterolaemia
and investigate further if the total cholesterol concentration is > 7.5 mmol/l and there is a family
history of premature coronary heart disease. They also recommend referring people with a total
cholesterol > 9.0 mmol/l or a non-HDL cholesterol (i.e. LDL) of > 7.5 mmol/l even in the absence of a
first-degree family history of premature coronary heart disease.

Interpreting the QRISK2 result

Probably the headline changes in the 2014 guidelines was the new, lower cut-off of 10-year CVD
risk cut-off of 10%.
NICE now recommend we offer a statin to people with a QRISK2 10-year risk of >= 10%
Lifestyle factors are of course important and NICE recommend that we give patients the option of
having their CVD risk reassessed after a period of time before starting a statin.
Atorvastatin 20mg should be offered first-line.

Special situations

Type 1 diabetes mellitus

NICE recommend that we 'consider statin treatment for the primary prevention of CVD in all
adults with type 1 diabetes'
atorvastatin 20 mg should be offered if type 1 diabetics who are:
older than 40 years, or
have had diabetes for more than 10 years or
have established nephropathy or
have other CVD risk factors

Chronic kidney disease (CKD)

atorvastatin 20mg should be offered to patients with CKD

increase the dose if a greater than 40% reduction in non-HDL cholesterol is not achieved
and the eGFR > 30 ml/min. If the eGFR is < 30 ml/min a renal specialist should be consulted
before increasing the dose

Secondary prevention
All patients with CVD should be taking a statin in the absence of any contraindication.
Atorvastatin 80mg should be offered first-line.

Follow-up of people started on statins

NICE recommend we follow-up patients at 3 months

repeat a full lipid profile

if the non-HDL cholesterol has not fallen by at least 40% concordance and lifestyle changes
should be discussed with the patient
NICE recommend we consider increasing the dose of atorvastatin up to 80mg

Lifestyle modifications
These are in many ways predictable but NICE make a number of specific points:
Cardioprotective diet

total fat intake should be <= 30% of total energy intake

saturated fats should be <= 7% of total energy intake

intake of dietary cholesterol should be < 300 mg/day
saturated fats should be replaced by monounsaturated and polyunsaturated fats where
possible
replace saturated and monounsaturated fat intake with olive oil, rapeseed oil or spreads
based on these oils
choose wholegrain varieties of starchy food
reduce their intake of sugar and food products containing refined sugars including fructose
eat at least 5 portions of fruit and vegetables per day

eat at least 2 portions of fish per week, including a portion of oily fish
eat at least 4 to 5 portions of unsalted nuts, seeds and legumes per week

Physical activity

each week aim for at least 150 minutes of moderate intensity aerobic activity or 75 minutes
of vigorous intensity aerobic activity or a mix of moderate and vigorous aerobic activity
do musclestrengthening activities on 2 or more days a week that work all major muscle
groups (legs, hips, back, abdomen, chest, shoulders and arms) in line with national guidance
for the general population

Weight management

no specific advice is given, overweight patients should be managed in keeping with relevant
NICE guidance

Alcohol intake

again no specific advice, other than the general recommendation that males drink no more
than 3-4 units/day and females no more than 2-3 units/day

Smoking cessation

smokers should be encouraged to quit

Next

Question 11 of 44

A 43-year-old man requests a 'medical' as he is concerned about his risk of heart disease. His father
died at the age of 45-years following a myocardial infarction. His lipid profile is as follows:
HDL

1.4 mmol/l

LDL

5.7 mmol/l

Triglycerides

2.3 mmol/l

Total cholesterol 8.2 mmol/l

Clinical examination reveals tendon xanthomata around his ankles. What is the most likely
diagnosis?
A. Mixed hyperlipidaemia
B. Nephrotic syndrome
C. Alcohol excess
D. Non-familial hypercholesterolaemia
E. Familial hypercholesterolaemia
Next question
The presence of tendon xanthomata and cholesterol levels meet the diagnostic criteria for familial
hypercholesterolaemia
Familial hypercholesterolaemia
Familial hypercholesterolaemia (FH) is an autosomal dominant condition that is thought to affect
around 1 in 500 people. It results in high levels of LDL-cholesterol which, if untreated, may cause
early cardiovascular disease (CVD). FH is caused by mutations in the gene which encodes the LDLreceptor protein.
Clinical diagnosis is now based on the Simon Broome criteria:

in adults total cholesterol (TC) > 7.5 mmol/l and LDL-C > 4.9 mmol/l or children TC > 6.7
mmol/l and LDL-C > 4.0 mmol/l, plus:

for definite FH: tendon xanthoma in patients or 1st or 2nd degree relatives or DNA-based
evidence of FH
for possible FH: family history of myocardial infarction below age 50 years in 2nd degree
relative, below age 60 in 1st degree relative, or a family history of raised cholesterol levels

Management

the use of CVD risk estimation using standard tables is not appropriate in FH as they do not

accurately reflect the risk of CVD

referral to a specialist lipid clinic is usually required

the maximum dose of potent statins are usually required

first-degree relatives have a 50% chance of having the disorder and should therefore be
offered screening. This includes children who should be screened by the age of 10 years if
there is one affected parent
statins should be discontinued in women 3 months before conception due to the risk of
congenital defects

Question 12 of 44

Next

A 67-year-old woman presents with lethargy, depression and constipation. A set of screening blood
tests reveals the following:
Calcium 3.05 mmol/l
Albumin 41 g/l

What is the single most useful test for determining the cause of her hypercalcaemia?
A. ESR
B. Phosphate
C. Vitamin D level
D. Parathyroid hormone

E. ACE level
Next question
Parathyroid hormone levels are useful as malignancy and primary hyperparathyroidism are the two
most common causes of hypercalcaemia. A parathyroid hormone that is normal or raised suggests
primary hyperparathyroidism.
Hypercalcaemia: causes
The most common causes of hypercalcaemia are malignancy (bone metastases, myeloma, PTHrP
from squamous cell lung cancer) and primary hyperparathyroidism
Other causes include

sarcoidosis*
vitamin D intoxication
acromegaly
thyrotoxicosis
Milk-alkali syndrome
drugs: thiazides, calcium containing antacids
dehydration
Addison's disease
Paget's disease of the bone**

*other causes of granulomas may lead to hypercalcaemia e.g. Tuberculosis and histoplasmosis
**usually normal in this condition but hypercalcaemia may occur with prolonged immobilisation

Question 13 of 44
Which one of the following patients is most likely to have their true risk of cardiovascular disease
underestimated by QRISK2?
A. A 54-year-old man with a history of schizophrenia who takes olanzapine
B. A 59-year-old man with a 14 year history of type 2 diabetes mellitus

Next

C. A 62-year-old man with body mass index of 34.1 kg/m

D. A 50-year-old man who drinks around 30-40 units of alcohol/week
E. A 67-year-old woman with a history of chronic obstructive pulmonary disease
Next question
QRISK2 may underestimate the risk of cardiovascular disease in patients with a serious mental
health disorder and those taking antipsychotics.
Hyperlipidaemia: management
In 2014 NICE updated their guidelines on lipid modification. This proved highly controversial as it
meant that we should be recommending statins to a significant proportion of the population over the
age of 60 years. Anyway, the key points of the new guidelines are summarised below.

Primary prevention - who and how to assess risk

A systematic strategy should be used to identify people aged over 40 years who are likely to be at
high risk of cardiovascular disease (CVD), defined as a 10-year risk of 10% or greater.
NICE recommend we use the QRISK2 CVD risk assessment tool for patients aged <= 84 years.
Patients >= 85 years are at high risk of CVD due to their age. QRISK2 should not be used in the
following situations as there are more specific guidelines for these patient groups:

type 1 diabetics
patients with an estimated glomerular filtration rate (eGFR) less than 60 ml/min and/or
albuminuria
patients with a history of familial hyperlipidaemia

NICE suggest QRISK2 may underestimate CVD risk in the following population groups:

people treated for HIV

people with serious mental health problems
people taking medicines that can cause dyslipidaemia such as antipsychotics, corticosteroids
or immunosuppressant drugs
people with autoimmune disorders/systemic inflammatory disorders such as systemic lupus
erythematosus

Measuring lipid levels

When measuring lipids both the total cholesterol and HDL should be checking to provide the most
accurate risk of CVD. A full lipid profile should also be checked (i.e. including triglycerides) before
starting a statin. The samples does not need to be fasting.
In the vast majority of patient the cholesterol measurements will be fed into the QRISK2 tool. If
however the patient's cholesterol is very high we should consider familial hyperlipidaemia. NICE
recommend the following that we should consider the possibility of familial hypercholesterolaemia
and investigate further if the total cholesterol concentration is > 7.5 mmol/l and there is a family
history of premature coronary heart disease. They also recommend referring people with a total
cholesterol > 9.0 mmol/l or a non-HDL cholesterol (i.e. LDL) of > 7.5 mmol/l even in the absence of a
first-degree family history of premature coronary heart disease.

Interpreting the QRISK2 result

Probably the headline changes in the 2014 guidelines was the new, lower cut-off of 10-year CVD
risk cut-off of 10%.
NICE now recommend we offer a statin to people with a QRISK2 10-year risk of >= 10%
Lifestyle factors are of course important and NICE recommend that we give patients the option of
having their CVD risk reassessed after a period of time before starting a statin.
Atorvastatin 20mg should be offered first-line.

Special situations
Type 1 diabetes mellitus

NICE recommend that we 'consider statin treatment for the primary prevention of CVD in all
adults with type 1 diabetes'
atorvastatin 20 mg should be offered if type 1 diabetics who are:
older than 40 years, or
have had diabetes for more than 10 years or
have established nephropathy or
have other CVD risk factors

Chronic kidney disease (CKD)

atorvastatin 20mg should be offered to patients with CKD

increase the dose if a greater than 40% reduction in non-HDL cholesterol is not achieved
and the eGFR > 30 ml/min. If the eGFR is < 30 ml/min a renal specialist should be consulted
before increasing the dose

Secondary prevention
All patients with CVD should be taking a statin in the absence of any contraindication.
Atorvastatin 80mg should be offered first-line.

Follow-up of people started on statins

NICE recommend we follow-up patients at 3 months

repeat a full lipid profile

if the non-HDL cholesterol has not fallen by at least 40% concordance and lifestyle changes
should be discussed with the patient
NICE recommend we consider increasing the dose of atorvastatin up to 80mg

Lifestyle modifications
These are in many ways predictable but NICE make a number of specific points:
Cardioprotective diet

total fat intake should be <= 30% of total energy intake

saturated fats should be <= 7% of total energy intake
intake of dietary cholesterol should be < 300 mg/day
saturated fats should be replaced by monounsaturated and polyunsaturated fats where
possible
replace saturated and monounsaturated fat intake with olive oil, rapeseed oil or spreads
based on these oils
choose wholegrain varieties of starchy food
reduce their intake of sugar and food products containing refined sugars including fructose
eat at least 5 portions of fruit and vegetables per day

eat at least 2 portions of fish per week, including a portion of oily fish
eat at least 4 to 5 portions of unsalted nuts, seeds and legumes per week

Physical activity

each week aim for at least 150 minutes of moderate intensity aerobic activity or 75 minutes
of vigorous intensity aerobic activity or a mix of moderate and vigorous aerobic activity
do musclestrengthening activities on 2 or more days a week that work all major muscle
groups (legs, hips, back, abdomen, chest, shoulders and arms) in line with national guidance
for the general population

Weight management

no specific advice is given, overweight patients should be managed in keeping with relevant
NICE guidance

Alcohol intake

again no specific advice, other than the general recommendation that males drink no more
than 3-4 units/day and females no more than 2-3 units/day

Smoking cessation

smokers should be encouraged to quit

Question 14 of 44

Next

A 60-year-old man who is known to have lung cancer comes for review. For the past three weeks he
has lost his appetite, has been feeling sick and generally feels tired. On examination he appears to
be mildly dehydrated. You order some blood tests:
Calcium

3.12 mmol/l

Albumin

40 g/l

Glucose (random) 6.7 mmol/l

Urea

10.2 mmol/l

Creatinine

115 mol/l

Which one of his existing medications is most likely to be contributing to his presentation?
A. Amlodipine
B. Simvastatin
C. Bendroflumethiazide
D. Aspirin
E. Lisinopril
Next question

Thiazides cause hypercalcaemia

Hypercalcaemia: causes
The most common causes of hypercalcaemia are malignancy (bone metastases, myeloma, PTHrP
from squamous cell lung cancer) and primary hyperparathyroidism
Other causes include

sarcoidosis*

vitamin D intoxication
acromegaly
thyrotoxicosis
Milk-alkali syndrome
drugs: thiazides, calcium containing antacids
dehydration
Addison's disease
Paget's disease of the bone**

*other causes of granulomas may lead to hypercalcaemia e.g. Tuberculosis and histoplasmosis
**usually normal in this condition but hypercalcaemia may occur with prolonged immobilisation

Next

Question 15 of 44

A 65-year-old Asian female presents to her GP with generalised bone pain and muscle weakness.
Investigations show:
Calcium

2.07 mmol/l

Phosphate 0.66 mmol/l

ALP

256 U/l

What is the most likely diagnosis?

A. Bone tuberculosis
B. Hypoparathyroidism
C. Myeloma
D. Osteomalacia
E. Paget's disease
Next question
The low calcium and phosphate combined with the raised alkaline phosphatase point towards
osteomalacia
Osteomalacia
Basics

normal bony tissue but decreased mineral content

rickets if when growing
osteomalacia if after epiphysis fusion

Types

vitamin D deficiency e.g. malabsorption, lack of sunlight, diet

renal failure
drug induced e.g. anticonvulsants
vitamin D resistant; inherited
liver disease, e.g. cirrhosis

Features

rickets: knock-knee, bow leg, features of hypocalcaemia

osteomalacia: bone pain, fractures, muscle tenderness, proximal myopathy

Investigation

low calcium, phosphate, 25(OH) vitamin D

raised alkaline phosphatase
x-ray: children - cupped, ragged metaphyseal surfaces; adults - translucent bands (Looser's
zones or pseudofractures)

Treatment

calcium with vitamin D tablets

Question 16 of 44

Next

A 46-year-old man with a history of hyperlipidaemia is reviewed in clinic. He is currently taking

simvastatin 10mg on but his cholesterol level remains high. Previous attempts to increase the dose
of simvastatin have resulted in myalgia. Given the history of myalgia, which lipid-regulating drug
should be avoided?
A. Nicotinic acid

B. Bezafibrate
C. Colestyramine
D. Omega-3 fatty acid
E. Ezetimibe
Next question
Tough question as both fibrates and nicotinic acid have been associated with myositis, especially
when combined with a statin. However, the Committee on Safety of Medicines has produced
guidance which specifically warns about the concomitant prescription of fibrates with statins in
relation to muscle toxicity
Hyperlipidaemia: mechanism of action and adverse effects
The following table compares the side-effects of drugs used in hyperlipidaemia:

Drugs

Mechanism of action

Adverse effects

Statins

HMG CoA reductase inhibitors

Myositis, deranged
LFTs

Ezetimibe

Decreases cholesterol absorption in the small intestine

Headache

Nicotinic acid

Decreases hepatic VLDL secretion

Flushing, myositis

Fibrates

Agonist of PPAR-alpha therefore increases lipoprotein lipase expression

Myositis, pruritus,
cholestasis

Cholestyramine

Decreases bile acid reabsorption in the small intestine, upregulating the

amount of cholesterol that is converted to bile acid

GI side-effects

Question 17 of 44

Next

A 40-year-old man presents to surgery as he has noted an abnormality around his right eye:

What is the most likely diagnosis?

A. Hypertriglyceridaemia
B. Hypercholesterolaemia
C. Hypothyroidism
D. Wilson's disease
E. Diabetes mellitus
Next question
This patient has developed xanthelasma secondary to hypercholesterolaemia.
Hyperlipidaemia: xanthomata
Characteristic xanthomata seen in hyperlipidaemia:
Palmar xanthoma

remnant hyperlipidaemia
may less commonly be seen in familial hypercholesterolaemia

Eruptive xanthoma are due to high triglyceride levels and present as multiple red/yellow vesicles on
the extensor surfaces (e.g. elbows, knees)
Causes of eruptive xanthoma

familial hypertriglyceridaemia
lipoprotein lipase deficiency

Tendon xanthoma, tuberous xanthoma, xanthelasma

familial hypercholesterolaemia
remnant hyperlipidaemia

Xanthelasma are also seen without lipid abnormalities

Management of xanthelasma, options include:

surgical excision

topical trichloroacetic acid

laser therapy
electrodesiccation

Question 18 of 44

Next

A 69-year-old man who had a stroke 3 years ago is reviewed. After his diagnosis he was started on
simvastatin 40mg on for secondary prevention of further cardiovascular disease. A fasting lipid
profile taken one week ago is reported as follows:
Total cholesterol

5.4 mmol/l

HDL cholesterol

1.0 mmol/l

LDL cholesterol

4.1 mmol/l

Triglyceride

1.5 mmol/l

According to recent NICE guidelines, what is the most appropriate action?

A. Switch to simvastatin 80mg on
B. No change in medication, repeat lipid profile in 6 months
C. Add nicotinic acid
D. Switch to atorvastatin 80mg on
E. Add ezetimibe
Next question
NICE guidelines changed in 2014 on the use of statins in both primary and secondary prevention.
Atorvastatin 80mg is now the treatment of choice for patients with established cardiovascular
disease. As the LDL cholesterol remains elevated it is appropriate to switch this patient.
Hyperlipidaemia: management
In 2014 NICE updated their guidelines on lipid modification. This proved highly controversial as it
meant that we should be recommending statins to a significant proportion of the population over the
age of 60 years. Anyway, the key points of the new guidelines are summarised below.

Primary prevention - who and how to assess risk

A systematic strategy should be used to identify people aged over 40 years who are likely to be at
high risk of cardiovascular disease (CVD), defined as a 10-year risk of 10% or greater.
NICE recommend we use the QRISK2 CVD risk assessment tool for patients aged <= 84 years.
Patients >= 85 years are at high risk of CVD due to their age. QRISK2 should not be used in the
following situations as there are more specific guidelines for these patient groups:

type 1 diabetics
patients with an estimated glomerular filtration rate (eGFR) less than 60 ml/min and/or
albuminuria
patients with a history of familial hyperlipidaemia

NICE suggest QRISK2 may underestimate CVD risk in the following population groups:

people treated for HIV

people with serious mental health problems
people taking medicines that can cause dyslipidaemia such as antipsychotics, corticosteroids
or immunosuppressant drugs
people with autoimmune disorders/systemic inflammatory disorders such as systemic lupus
erythematosus

Measuring lipid levels

When measuring lipids both the total cholesterol and HDL should be checking to provide the most
accurate risk of CVD. A full lipid profile should also be checked (i.e. including triglycerides) before
starting a statin. The samples does not need to be fasting.
In the vast majority of patient the cholesterol measurements will be fed into the QRISK2 tool. If
however the patient's cholesterol is very high we should consider familial hyperlipidaemia. NICE
recommend the following that we should consider the possibility of familial hypercholesterolaemia
and investigate further if the total cholesterol concentration is > 7.5 mmol/l and there is a family
history of premature coronary heart disease. They also recommend referring people with a total
cholesterol > 9.0 mmol/l or a non-HDL cholesterol (i.e. LDL) of > 7.5 mmol/l even in the absence of a
first-degree family history of premature coronary heart disease.

Interpreting the QRISK2 result

Probably the headline changes in the 2014 guidelines was the new, lower cut-off of 10-year CVD
risk cut-off of 10%.
NICE now recommend we offer a statin to people with a QRISK2 10-year risk of >= 10%
Lifestyle factors are of course important and NICE recommend that we give patients the option of
having their CVD risk reassessed after a period of time before starting a statin.
Atorvastatin 20mg should be offered first-line.

Special situations

Type 1 diabetes mellitus

NICE recommend that we 'consider statin treatment for the primary prevention of CVD in all
adults with type 1 diabetes'
atorvastatin 20 mg should be offered if type 1 diabetics who are:
older than 40 years, or
have had diabetes for more than 10 years or
have established nephropathy or
have other CVD risk factors

Chronic kidney disease (CKD)

atorvastatin 20mg should be offered to patients with CKD

increase the dose if a greater than 40% reduction in non-HDL cholesterol is not achieved
and the eGFR > 30 ml/min. If the eGFR is < 30 ml/min a renal specialist should be consulted
before increasing the dose

Secondary prevention
All patients with CVD should be taking a statin in the absence of any contraindication.
Atorvastatin 80mg should be offered first-line.

Follow-up of people started on statins

NICE recommend we follow-up patients at 3 months

repeat a full lipid profile

if the non-HDL cholesterol has not fallen by at least 40% concordance and lifestyle changes
should be discussed with the patient
NICE recommend we consider increasing the dose of atorvastatin up to 80mg

Lifestyle modifications
These are in many ways predictable but NICE make a number of specific points:
Cardioprotective diet

total fat intake should be <= 30% of total energy intake

saturated fats should be <= 7% of total energy intake

intake of dietary cholesterol should be < 300 mg/day
saturated fats should be replaced by monounsaturated and polyunsaturated fats where
possible
replace saturated and monounsaturated fat intake with olive oil, rapeseed oil or spreads
based on these oils
choose wholegrain varieties of starchy food
reduce their intake of sugar and food products containing refined sugars including fructose
eat at least 5 portions of fruit and vegetables per day

eat at least 2 portions of fish per week, including a portion of oily fish
eat at least 4 to 5 portions of unsalted nuts, seeds and legumes per week

Physical activity

each week aim for at least 150 minutes of moderate intensity aerobic activity or 75 minutes
of vigorous intensity aerobic activity or a mix of moderate and vigorous aerobic activity
do musclestrengthening activities on 2 or more days a week that work all major muscle
groups (legs, hips, back, abdomen, chest, shoulders and arms) in line with national guidance
for the general population

Weight management

no specific advice is given, overweight patients should be managed in keeping with relevant
NICE guidance

Alcohol intake

again no specific advice, other than the general recommendation that males drink no more
than 3-4 units/day and females no more than 2-3 units/day

Smoking cessation

smokers should be encouraged to quit

Question 19 of 44

Next

A 68-year-old Asian women comes for advice. She is concerned about vitamin D deficiency after
reading an article in the newspaper. She is generally fit and well and specifically does not have any
muscle/bone pain or weakness. Her only past medical history of note is hypertension and spinal
stenosis. She does not cover her head for cultural reasons. What is the most appropriate advice to
give?
A. Without any symptoms of osteomalacia no further action is required
B. She should take vitamin D 10mcg od
C. She should complete a food diary and come back in 2 weeks time for review
D. A vitamin D test should be done
E. A DEXA scan should be arranged
Next question
People who are at higher risk of vitamin D deficiency (in this scenario age > 65 years, pigmented
skin) should be treated anyway so testing is not necessary.
Vitamin D supplementation
Vitamin D supplementation has been a hot topic for a number of years now. The muddied waters are
now slightly clearer following the release of the following:

2012: letter by the Chief Medical Officer regarding vitamin D supplementation

2013: National Osteoporosis Society (NOS) release UK Vitamin D guideline

The following groups should be advised to take vitamin D supplementation:

all pregnant and breastfeeding women should take a daily supplement containing 10g of
vitamin D
all children aged 6 months - 5 years. Babies fed with formula milk do not need to take a
supplement if they are taking more than 500ml of milk a day, as formula milk is fortified with
vitamin D
adults > 65 years

'people who are not exposed to much sun should also take a daily supplement'

Testing for vitamin D deficiency

The key message is that not many people warrant a vitamin D test. The NOS guidelines specify that
testing may be appropriate in the following situtations:

patients with bone diseases that may be improved with vitamin D treatment e.g. known

osteomalacia or Paget's disease

patients with bone diseases, prior to specific treatment where correcting vitamin deficiency is

appropriate e,g, prior to intravenous zolendronate or denosumab

patients with musculoskeletal symptoms that could be attributed to vitamin D deficiency e.g.
bone pain ?osteomalacia

Patients with osteoporosis should always be given calcium/vitamin D supplements to testing is not
considered necessary. People who are at higher risk of vitamin D deficiency (see above) should be
treated anyway so again testing is not necessary.

Question 20 of 44

Next

Your next patient is an 18-year-old man who has Down's syndrome. He had acute lymphoblastic
leukaemia as a child but made a full recovery. He is also slightly overweight with a BMI of 28 kg/m.
Which one of the following best describes the monitoring he should have?
A. Cholesterol every 12 months
B. HbA1c every 2 years
C. HbA1c every 12 months
D. TSH every 2 years
E. TSH every 12 months
Next question

Specific QOF markers

It is unlikely that the examiners would expect you to have a detailed knowledge of the Quality and
Outcomes Framework (QOF) for the exam, particularly as the markers can change on a regular
basis. They may however provide a useful 'summary of evidence' of targets and how often certain
things should be done.
Remember that QOF often describes a minimum standard of care and more specific guidelines (e.g.
NICE) should be followed when determining the best course of action, whether in clinical practice or
in the exam.
The table below therefore gives a very limited summary of such points:

Condition

Recommendation

Coronary heart disease, cerebrovascular disease, peripheral arterial

disease, diabetes mellitus

Target cholesterol < 5 mmol/l

Down's syndrome

TSH measured every 12 months

Schizophrenia, bipolar affective disorder

The following should be recorded every 12

months:

Question 21 of 44

blood pressure
total cholesterol:HDL ratio,
HbA1c
body mass index

Next

A 45-year-old man with a persistent chest infection presents to surgery for review. He has now had
two courses of antibiotics with no real improvement. A decision is made to perform a chest x-ray and
do screening blood tests. When interpreting the blood tests which one of the following would not
normally be raised in response to an acute infection?
A. CRP

B. Platelets
C. ESR
D. Albumin
E. Ferritin
Next question
Albumin levels are often reduced following an acute phase response
Acute phase proteins
Acute phase proteins

CRP
procalcitonin
ferritin
fibrinogen
alpha-1 antitrypsin
caeruloplasmin
serum amyloid A
serum amyloid P component*
haptoglobin
complement

During the acute phase response the liver decreases the production of other proteins (sometimes
referred to as negative acute phase proteins). Examples include:

albumin
transthyretin (formerly known as prealbumin)
transferrin
retinol binding protein
cortisol binding protein

*plays a more significant role in other mammals such as mice

Next

Question 22 of 44
You are reviewing the blood results for a patient who was started on atorvastatin 20mg on for
primary prevention 3 months ago:

Recent
3 months ago prior to starting treatment
Total cholesterol
4.2 mmol/l 6.3 mmol/l
HDL cholesterol
1.1 mmol/l 1.0 mmol/l
Non-HDL cholesterol 2.1 mmol/l 4.0 mmol/l
Triglyceride
1.2 mmol/l 1.3 mmol/l
Liver function tests are normal.
What is the most appropriate course of action?
A. Reduce atorvastatin to 10mg on
B. Make no changes to medication
C. Increase atorvastatin to 40mg on
D. Check creatine kinase
E. Check compliance
Next question
NICE look for a 40% reduction in non-HDL cholesterol after 3 months. A 10% reduction in a nonHDL cholesterol of 4.0 would be 0.4 so a 40% reduction would take it down to (4.0 - 1.6 = 2.4
mmol/l). This patients non-HDL cholesterol of 2.1 mmol/l is therefore acceptable.
Hyperlipidaemia: management
In 2014 NICE updated their guidelines on lipid modification. This proved highly controversial as it
meant that we should be recommending statins to a significant proportion of the population over the
age of 60 years. Anyway, the key points of the new guidelines are summarised below.

Primary prevention - who and how to assess risk

A systematic strategy should be used to identify people aged over 40 years who are likely to be at

high risk of cardiovascular disease (CVD), defined as a 10-year risk of 10% or greater.
NICE recommend we use the QRISK2 CVD risk assessment tool for patients aged <= 84 years.
Patients >= 85 years are at high risk of CVD due to their age. QRISK2 should not be used in the
following situations as there are more specific guidelines for these patient groups:

type 1 diabetics
patients with an estimated glomerular filtration rate (eGFR) less than 60 ml/min and/or
albuminuria
patients with a history of familial hyperlipidaemia

NICE suggest QRISK2 may underestimate CVD risk in the following population groups:

people treated for HIV

people with serious mental health problems
people taking medicines that can cause dyslipidaemia such as antipsychotics, corticosteroids
or immunosuppressant drugs
people with autoimmune disorders/systemic inflammatory disorders such as systemic lupus
erythematosus

Measuring lipid levels

When measuring lipids both the total cholesterol and HDL should be checking to provide the most
accurate risk of CVD. A full lipid profile should also be checked (i.e. including triglycerides) before
starting a statin. The samples does not need to be fasting.
In the vast majority of patient the cholesterol measurements will be fed into the QRISK2 tool. If
however the patient's cholesterol is very high we should consider familial hyperlipidaemia. NICE
recommend the following that we should consider the possibility of familial hypercholesterolaemia
and investigate further if the total cholesterol concentration is > 7.5 mmol/l and there is a family
history of premature coronary heart disease. They also recommend referring people with a total
cholesterol > 9.0 mmol/l or a non-HDL cholesterol (i.e. LDL) of > 7.5 mmol/l even in the absence of a
first-degree family history of premature coronary heart disease.

Interpreting the QRISK2 result

Probably the headline changes in the 2014 guidelines was the new, lower cut-off of 10-year CVD

risk cut-off of 10%.

NICE now recommend we offer a statin to people with a QRISK2 10-year risk of >= 10%
Lifestyle factors are of course important and NICE recommend that we give patients the option of
having their CVD risk reassessed after a period of time before starting a statin.
Atorvastatin 20mg should be offered first-line.

Special situations
Type 1 diabetes mellitus

NICE recommend that we 'consider statin treatment for the primary prevention of CVD in all
adults with type 1 diabetes'
atorvastatin 20 mg should be offered if type 1 diabetics who are:
older than 40 years, or
have had diabetes for more than 10 years or
have established nephropathy or
have other CVD risk factors

Chronic kidney disease (CKD)

atorvastatin 20mg should be offered to patients with CKD

increase the dose if a greater than 40% reduction in non-HDL cholesterol is not achieved
and the eGFR > 30 ml/min. If the eGFR is < 30 ml/min a renal specialist should be consulted
before increasing the dose

Secondary prevention
All patients with CVD should be taking a statin in the absence of any contraindication.
Atorvastatin 80mg should be offered first-line.

Follow-up of people started on statins

NICE recommend we follow-up patients at 3 months

repeat a full lipid profile

if the non-HDL cholesterol has not fallen by at least 40% concordance and lifestyle changes
should be discussed with the patient
NICE recommend we consider increasing the dose of atorvastatin up to 80mg

Lifestyle modifications
These are in many ways predictable but NICE make a number of specific points:
Cardioprotective diet

total fat intake should be <= 30% of total energy intake

saturated fats should be <= 7% of total energy intake
intake of dietary cholesterol should be < 300 mg/day
saturated fats should be replaced by monounsaturated and polyunsaturated fats where
possible
replace saturated and monounsaturated fat intake with olive oil, rapeseed oil or spreads
based on these oils
choose wholegrain varieties of starchy food
reduce their intake of sugar and food products containing refined sugars including fructose
eat at least 5 portions of fruit and vegetables per day
eat at least 2 portions of fish per week, including a portion of oily fish
eat at least 4 to 5 portions of unsalted nuts, seeds and legumes per week

Physical activity

each week aim for at least 150 minutes of moderate intensity aerobic activity or 75 minutes
of vigorous intensity aerobic activity or a mix of moderate and vigorous aerobic activity
do musclestrengthening activities on 2 or more days a week that work all major muscle
groups (legs, hips, back, abdomen, chest, shoulders and arms) in line with national guidance
for the general population

Weight management

no specific advice is given, overweight patients should be managed in keeping with relevant
NICE guidance

Alcohol intake

again no specific advice, other than the general recommendation that males drink no more
than 3-4 units/day and females no more than 2-3 units/day

Smoking cessation

smokers should be encouraged to quit

Next

Question 23 of 44

Which one of the following medications used in the management of hyperlipidaemia is most likely to
cause flushing?
A. Bezafibrate
B. Ezetimibe
C. Nicotinic acid
D. Atorvastatin
E. Cholestyramine
Next question

Hyperlipidaemia: mechanism of action and adverse effects

The following table compares the side-effects of drugs used in hyperlipidaemia:

Drugs

Mechanism of action

Adverse effects

Statins

HMG CoA reductase inhibitors

Myositis, deranged
LFTs

Ezetimibe

Decreases cholesterol absorption in the small intestine

Headache

Nicotinic acid

Decreases hepatic VLDL secretion

Flushing, myositis

Fibrates

Agonist of PPAR-alpha therefore increases lipoprotein lipase expression

Myositis, pruritus,
cholestasis

Cholestyramine

Decreases bile acid reabsorption in the small intestine, upregulating the

amount of cholesterol that is converted to bile acid

GI side-effects

Question 24 of 44

Next

A 42-year-old man is reviewed in clinic after recently having some bloods taken. He requested
screening for 'heart disease' as his father died of a myocardial infarction aged 52-years. Today his
blood pressure is 130/84 mmHg and body mass index is 26 kg/m. He is a non-smoker.
His recent bloods showed the following

Na+
142 mmol/l
K+
3.6 mmol/l
Urea
5.5 mmol/l
Creatinine 80 mol/l

Total cholesterol 7.9 mmol/l

HDL cholesterol 1.4 mmol/l
LDL cholesterol 5.5 mmol/l
Triglyceride
1.4 mmol/l
Fasting glucose 5.2 mmol/l
You calculate his QRISK2 as 4.2%. What is the most appropriate course of action?
A. Start atorvastatin 40mg on
B. Start atorvastatin 80mg on
C. Refer him to a specialist lipids clinic
D. Reassure him that his risk of cardiovascular disease is low

E. Start atorvastatin 20mg on

Next question
In the 2014 NICE lipid modification guidelines a number of recommendations were made regarding
familial hyperlipidaemia. NICE recommends the following:

Consider the possibility of familial hypercholesterolaemia and investigate as described in Familial

hypercholesterolaemia (NICE clinical guideline 71) if they have:

a total cholesterol concentration more than 7.5 mmol/litre and

a family history of premature coronary heart disease.

Arrange for specialist assessment of people with a total cholesterol concentration of more than 9.0
mmol/litre or a nonHDL cholesterol concentration of more than 7.5 mmol/litre even in the absence of
a firstdegree family history of premature coronary heart disease.

Hyperlipidaemia: management
In 2014 NICE updated their guidelines on lipid modification. This proved highly controversial as it
meant that we should be recommending statins to a significant proportion of the population over the
age of 60 years. Anyway, the key points of the new guidelines are summarised below.

Primary prevention - who and how to assess risk

A systematic strategy should be used to identify people aged over 40 years who are likely to be at
high risk of cardiovascular disease (CVD), defined as a 10-year risk of 10% or greater.
NICE recommend we use the QRISK2 CVD risk assessment tool for patients aged <= 84 years.
Patients >= 85 years are at high risk of CVD due to their age. QRISK2 should not be used in the
following situations as there are more specific guidelines for these patient groups:

type 1 diabetics
patients with an estimated glomerular filtration rate (eGFR) less than 60 ml/min and/or
albuminuria
patients with a history of familial hyperlipidaemia

NICE suggest QRISK2 may underestimate CVD risk in the following population groups:

people treated for HIV

people with serious mental health problems
people taking medicines that can cause dyslipidaemia such as antipsychotics, corticosteroids
or immunosuppressant drugs
people with autoimmune disorders/systemic inflammatory disorders such as systemic lupus
erythematosus

Measuring lipid levels

When measuring lipids both the total cholesterol and HDL should be checking to provide the most
accurate risk of CVD. A full lipid profile should also be checked (i.e. including triglycerides) before
starting a statin. The samples does not need to be fasting.
In the vast majority of patient the cholesterol measurements will be fed into the QRISK2 tool. If
however the patient's cholesterol is very high we should consider familial hyperlipidaemia. NICE
recommend the following that we should consider the possibility of familial hypercholesterolaemia
and investigate further if the total cholesterol concentration is > 7.5 mmol/l and there is a family
history of premature coronary heart disease. They also recommend referring people with a total
cholesterol > 9.0 mmol/l or a non-HDL cholesterol (i.e. LDL) of > 7.5 mmol/l even in the absence of a
first-degree family history of premature coronary heart disease.

Interpreting the QRISK2 result

Probably the headline changes in the 2014 guidelines was the new, lower cut-off of 10-year CVD
risk cut-off of 10%.
NICE now recommend we offer a statin to people with a QRISK2 10-year risk of >= 10%
Lifestyle factors are of course important and NICE recommend that we give patients the option of
having their CVD risk reassessed after a period of time before starting a statin.
Atorvastatin 20mg should be offered first-line.

Special situations

Type 1 diabetes mellitus

NICE recommend that we 'consider statin treatment for the primary prevention of CVD in all
adults with type 1 diabetes'
atorvastatin 20 mg should be offered if type 1 diabetics who are:
older than 40 years, or
have had diabetes for more than 10 years or
have established nephropathy or
have other CVD risk factors

Chronic kidney disease (CKD)

atorvastatin 20mg should be offered to patients with CKD

increase the dose if a greater than 40% reduction in non-HDL cholesterol is not achieved
and the eGFR > 30 ml/min. If the eGFR is < 30 ml/min a renal specialist should be consulted
before increasing the dose

Secondary prevention
All patients with CVD should be taking a statin in the absence of any contraindication.
Atorvastatin 80mg should be offered first-line.

Follow-up of people started on statins

NICE recommend we follow-up patients at 3 months

repeat a full lipid profile

if the non-HDL cholesterol has not fallen by at least 40% concordance and lifestyle changes
should be discussed with the patient
NICE recommend we consider increasing the dose of atorvastatin up to 80mg

Lifestyle modifications
These are in many ways predictable but NICE make a number of specific points:
Cardioprotective diet

total fat intake should be <= 30% of total energy intake

saturated fats should be <= 7% of total energy intake

intake of dietary cholesterol should be < 300 mg/day
saturated fats should be replaced by monounsaturated and polyunsaturated fats where
possible
replace saturated and monounsaturated fat intake with olive oil, rapeseed oil or spreads
based on these oils
choose wholegrain varieties of starchy food
reduce their intake of sugar and food products containing refined sugars including fructose
eat at least 5 portions of fruit and vegetables per day

eat at least 2 portions of fish per week, including a portion of oily fish
eat at least 4 to 5 portions of unsalted nuts, seeds and legumes per week

Physical activity

each week aim for at least 150 minutes of moderate intensity aerobic activity or 75 minutes
of vigorous intensity aerobic activity or a mix of moderate and vigorous aerobic activity
do musclestrengthening activities on 2 or more days a week that work all major muscle
groups (legs, hips, back, abdomen, chest, shoulders and arms) in line with national guidance
for the general population

Weight management

no specific advice is given, overweight patients should be managed in keeping with relevant
NICE guidance

Alcohol intake

again no specific advice, other than the general recommendation that males drink no more
than 3-4 units/day and females no more than 2-3 units/day

Smoking cessation

smokers should be encouraged to quit

Question 25 of 44

Next

Which one of the following patients should have their vitamin D status checked?
A. A patient with newly diagnosed osteoporosis who is about to start oral
alendronate
B. A patient who has been found to be hypercalcaemic
C. An immigrant from South-East Asia who is 70-years-old
D. A patient with newly diagnosed Paget's disease
E. A woman who 10-weeks pregnant
Next question

Vitamin D supplementation
Vitamin D supplementation has been a hot topic for a number of years now. The muddied waters are
now slightly clearer following the release of the following:

2012: letter by the Chief Medical Officer regarding vitamin D supplementation

2013: National Osteoporosis Society (NOS) release UK Vitamin D guideline

The following groups should be advised to take vitamin D supplementation:

all pregnant and breastfeeding women should take a daily supplement containing 10g of
vitamin D
all children aged 6 months - 5 years. Babies fed with formula milk do not need to take a
supplement if they are taking more than 500ml of milk a day, as formula milk is fortified with
vitamin D
adults > 65 years
'people who are not exposed to much sun should also take a daily supplement'

Testing for vitamin D deficiency

The key message is that not many people warrant a vitamin D test. The NOS guidelines specify that
testing may be appropriate in the following situtations:

patients with bone diseases that may be improved with vitamin D treatment e.g. known
osteomalacia or Paget's disease
patients with bone diseases, prior to specific treatment where correcting vitamin deficiency is
appropriate e,g, prior to intravenous zolendronate or denosumab
patients with musculoskeletal symptoms that could be attributed to vitamin D deficiency e.g.
bone pain ?osteomalacia

Patients with osteoporosis should always be given calcium/vitamin D supplements to testing is not
considered necessary. People who are at higher risk of vitamin D deficiency (see above) should be
treated anyway so again testing is not necessary.

Question 26 of 44

Next

A 54-year-old man is reviewed in clinic. He has recently started atorvastatin 20mg after it was found
that his QRISK2 score was 16%. He asks you about any changes he should make to his diet. Which
one of the following is a part of NICE's current advice on a cardioprotective diet?
A. Eat at lease 7 portions of fruit and vegetables a day
B. Increase the amount of fructose in diet
C. Eat at least 4 to 5 portions of unsalted nuts, seeds and legumes per week
D. Saturated fats should be between 7-10% of total energy intake
E. Monounsaturated spreads are preferred to those derived from olive oil
Next question

Hyperlipidaemia: management

In 2014 NICE updated their guidelines on lipid modification. This proved highly controversial as it
meant that we should be recommending statins to a significant proportion of the population over the
age of 60 years. Anyway, the key points of the new guidelines are summarised below.

Primary prevention - who and how to assess risk

A systematic strategy should be used to identify people aged over 40 years who are likely to be at
high risk of cardiovascular disease (CVD), defined as a 10-year risk of 10% or greater.
NICE recommend we use the QRISK2 CVD risk assessment tool for patients aged <= 84 years.
Patients >= 85 years are at high risk of CVD due to their age. QRISK2 should not be used in the
following situations as there are more specific guidelines for these patient groups:

type 1 diabetics
patients with an estimated glomerular filtration rate (eGFR) less than 60 ml/min and/or
albuminuria
patients with a history of familial hyperlipidaemia

NICE suggest QRISK2 may underestimate CVD risk in the following population groups:

people treated for HIV

people with serious mental health problems
people taking medicines that can cause dyslipidaemia such as antipsychotics, corticosteroids
or immunosuppressant drugs
people with autoimmune disorders/systemic inflammatory disorders such as systemic lupus
erythematosus

Measuring lipid levels

When measuring lipids both the total cholesterol and HDL should be checking to provide the most
accurate risk of CVD. A full lipid profile should also be checked (i.e. including triglycerides) before
starting a statin. The samples does not need to be fasting.
In the vast majority of patient the cholesterol measurements will be fed into the QRISK2 tool. If
however the patient's cholesterol is very high we should consider familial hyperlipidaemia. NICE
recommend the following that we should consider the possibility of familial hypercholesterolaemia

and investigate further if the total cholesterol concentration is > 7.5 mmol/l and there is a family
history of premature coronary heart disease. They also recommend referring people with a total
cholesterol > 9.0 mmol/l or a non-HDL cholesterol (i.e. LDL) of > 7.5 mmol/l even in the absence of a
first-degree family history of premature coronary heart disease.

Interpreting the QRISK2 result

Probably the headline changes in the 2014 guidelines was the new, lower cut-off of 10-year CVD
risk cut-off of 10%.
NICE now recommend we offer a statin to people with a QRISK2 10-year risk of >= 10%
Lifestyle factors are of course important and NICE recommend that we give patients the option of
having their CVD risk reassessed after a period of time before starting a statin.
Atorvastatin 20mg should be offered first-line.

Special situations
Type 1 diabetes mellitus

NICE recommend that we 'consider statin treatment for the primary prevention of CVD in all
adults with type 1 diabetes'
atorvastatin 20 mg should be offered if type 1 diabetics who are:
older than 40 years, or
have had diabetes for more than 10 years or
have established nephropathy or
have other CVD risk factors

Chronic kidney disease (CKD)

atorvastatin 20mg should be offered to patients with CKD

increase the dose if a greater than 40% reduction in non-HDL cholesterol is not achieved
and the eGFR > 30 ml/min. If the eGFR is < 30 ml/min a renal specialist should be consulted
before increasing the dose

Secondary prevention

All patients with CVD should be taking a statin in the absence of any contraindication.
Atorvastatin 80mg should be offered first-line.

Follow-up of people started on statins

NICE recommend we follow-up patients at 3 months

repeat a full lipid profile

if the non-HDL cholesterol has not fallen by at least 40% concordance and lifestyle changes
should be discussed with the patient
NICE recommend we consider increasing the dose of atorvastatin up to 80mg

Lifestyle modifications
These are in many ways predictable but NICE make a number of specific points:
Cardioprotective diet

total fat intake should be <= 30% of total energy intake

saturated fats should be <= 7% of total energy intake

intake of dietary cholesterol should be < 300 mg/day
saturated fats should be replaced by monounsaturated and polyunsaturated fats where
possible
replace saturated and monounsaturated fat intake with olive oil, rapeseed oil or spreads
based on these oils
choose wholegrain varieties of starchy food
reduce their intake of sugar and food products containing refined sugars including fructose
eat at least 5 portions of fruit and vegetables per day
eat at least 2 portions of fish per week, including a portion of oily fish
eat at least 4 to 5 portions of unsalted nuts, seeds and legumes per week

Physical activity

each week aim for at least 150 minutes of moderate intensity aerobic activity or 75 minutes
of vigorous intensity aerobic activity or a mix of moderate and vigorous aerobic activity

do musclestrengthening activities on 2 or more days a week that work all major muscle
groups (legs, hips, back, abdomen, chest, shoulders and arms) in line with national guidance
for the general population

Weight management

no specific advice is given, overweight patients should be managed in keeping with relevant
NICE guidance

Alcohol intake

again no specific advice, other than the general recommendation that males drink no more
than 3-4 units/day and females no more than 2-3 units/day

Smoking cessation

smokers should be encouraged to quit

Question 27 of 44

Next

How common is the heterozygous form of familial hypercholesterolaemia?

A. 1 in 20 people
B. 1 in 50 people
C. 1 in 100 people
D. 1 in 200 people
E. 1 in 500 people
Next question

Familial hypercholesterolaemia
Familial hypercholesterolaemia (FH) is an autosomal dominant condition that is thought to affect
around 1 in 500 people. It results in high levels of LDL-cholesterol which, if untreated, may cause
early cardiovascular disease (CVD). FH is caused by mutations in the gene which encodes the LDLreceptor protein.
Clinical diagnosis is now based on the Simon Broome criteria:

in adults total cholesterol (TC) > 7.5 mmol/l and LDL-C > 4.9 mmol/l or children TC > 6.7
mmol/l and LDL-C > 4.0 mmol/l, plus:
for definite FH: tendon xanthoma in patients or 1st or 2nd degree relatives or DNA-based
evidence of FH
for possible FH: family history of myocardial infarction below age 50 years in 2nd degree
relative, below age 60 in 1st degree relative, or a family history of raised cholesterol levels

Management

the use of CVD risk estimation using standard tables is not appropriate in FH as they do not
accurately reflect the risk of CVD
referral to a specialist lipid clinic is usually required
the maximum dose of potent statins are usually required
first-degree relatives have a 50% chance of having the disorder and should therefore be
offered screening. This includes children who should be screened by the age of 10 years if
there is one affected parent
statins should be discontinued in women 3 months before conception due to the risk of
congenital defects

Question 28 of 44
A 69-year-old female with a history of multiple myeloma presents with confusion. Blood tests are
taken and the following results are obtained:
Adjusted calcium 3.1 mmol/l

Next

What is the most appropriate initial management?

A. Oral alendronate + prednisolone
B. Oral alendronate
C. Oral prednisolone
D. Admit for IV pamidronate
E. Admit for IV normal saline
Next question

Hypercalcaemia: management
The initial management of hypercalcaemia is rehydration with normal saline, typically 3-4 litres/day.
Following rehydration bisphosphonates may be used. They typically take 2-3 days to work with
maximal effect being seen at 7 days
Other options include:

calcitonin - quicker effect than bisphosphonates

steroids in sarcoidosis

There is a limited role for the use of furosemide in hypercalcaemia. It may be useful in patients who
cannot tolerate aggressive fluid rehydration

Question 29 of 44
A 17-year-old girl presents to her GP with a 6 week history of nausea and abdominal discomfort.
Routine blood tests reveal the following.
Hb

11.9 g/dl

Next

WBC

6.7 *109/l

Platelets 346 *109/l

Calcium

2.43 mmol/l

Bilirubin 7 mol/l
ALP

262 u/l

ALT

35 u/l

What is the most likely diagnosis?

A. Alcoholic liver disease
B. Cholangiocarcinoma
C. Pregnancy
D. Gallstones
E. Primary biliary cirrhosis
Next question
Alkaline phosphatase is significantly elevated in pregnancy
Alkaline phosphatase
Causes of raised alkaline phosphatase (ALP)

liver: cholestasis, hepatitis, fatty liver, neoplasia

Paget's
osteomalacia
bone metastases
hyperparathyroidism
renal failure
physiological: pregnancy, growing children, healing fractures

The table below splits the causes according to the calcium level

Raised ALP and raised calcium

Raised ALP and low calcium

Bone metastases
Hyperparathyroidism

Osteomalacia
Renal failure

Question 30 of 44

Next

You are advising a patient who has recently been diagnosed with chronic kidney disease stage 4
with regards to her diet. Which one of the following foods should she eat in moderation due to the
high potassium content?
A. Tomatoes
B. Plums
C. Cranberry juice
D. Grapes
E. Green beans
Next question

Hyperkalaemia
Plasma potassium levels are regulated by a number of factors including aldosterone, acid-base
balance and insulin levels. Metabolic acidosis is associated with hyperkalaemia as hydrogen and
potassium ions compete with each other for exchange with sodium ions across cell membranes and
in the distal tubule. ECG changes seen in hyperkalaemia include tall-tented T waves, small P waves,
widened QRS leading to a sinusoidal pattern and asystole
Causes of hyperkalaemia:

acute renal failure

drugs*: potassium sparing diuretics, ACE inhibitors, angiotensin 2 receptor blockers,

spironolactone, ciclosporin, heparin**
metabolic acidosis
Addison's
rhabdomyolysis
massive blood transfusion

Foods that are high in potassium:

salt substitutes (i.e. Contain potassium rather than sodium)

bananas, oranges, kiwi fruit, avocado, spinach, tomatoes

*beta-blockers interfere with potassium transport into cells and can potentially cause hyperkalaemia
in renal failure patients - remember beta-agonists, e.g. Salbutamol, are sometimes used as
emergency treatment
**both unfractionated and low-molecular weight heparin can cause hyperkalaemia. This is thought to
be caused by inhibition of aldosterone secretion

Question 31 of 44

Next

A 55-year-old man with a history of type 2 diabetes mellitus, bipolar disorder and chronic obstructive
pulmonary disease has bloods taken as part of his annual diabetic review:
Na+

129 mmol/l

K+

3.8 mmol/l

Bicarbonate 24 mmol/l
Urea

3.7 mmol/l

Creatinine

92 mol/l

Due to his smoking history a chest x-ray is ordered which is reported as normal. Which one of the
following medications is most likely to be responsible?

A. Metformin
B. Sodium valproate
C. Carbamazepine
D. Betamethasone dipropionate inhaler
E. Exenatide
Next question

SIADH - drug causes: carbamazepine, sulfonylureas, SSRIs, tricyclics

Carbamazepine is used for bipolar disorder that hasn't responded to first-line drugs
SIADH: causes
The syndrome of inappropriate ADH secretion (SIADH) is characterised by hyponatraemia
secondary to the dilutional effects of excessive water retention.
Causes of SIADH

Category

Examples

Malignancy

small cell lung cancer

also: pancreas, prostate

Neurological

stroke
subarachnoid haemorrhage
subdural haemorrhage
meningitis/encephalitis/abscess

Infections

tuberculosis
pneumonia

Drugs

sulfonylureas

Other causes

SSRIs, tricyclics
carbamazepine
vincristine
cyclophosphamide

positive end-expiratory pressure (PEEP)

porphyrias

Management

correction must be done slowly to avoid precipitating central pontine myelinolysis

fluid restriction
demeclocycline: reduces the responsiveness of the collecting tubule cells to ADH
ADH (vasopressin) receptor antagonists have been developed

Question 32 of 44

Next

A 70-year-old woman is reviewed in the chronic kidney disease clinic. She also has a history of
hypertension for which she takes amlodipine 5mg od and ramipril 10mg od. Her most recent results
are as follows:
Blood pressure today is 128/74 mmHg.

Recent
12 months ago
Na
140 mmol/l 141 mmol/l
+
K
4.5 mmol/l 4.3 mmol/l
Urea
11.2 mmol/l 10.5 mmol/l
Creatinine 124 mol/l 114 mol/l
eGFR
39 ml/min 43 ml/min
+

What is the most appropriate next step in management?

A. Start atorvastatin 20mg on

B. Reduce ramipril to 5mg od and recheck U&Es in 4 weeks
C. Start simvastatin 40mg on
D. Increase amlodipine to 10mg od
E. Check her QRISK2 score
Next question
QRISK2 should not be used in patients with chronic kidney diseas (CKD). NICE now recommends
that all patients with CKD should take a statin.

Offer atorvastatin 20 mg for the primary or secondary prevention of CVD to people with CKD

Increase thedose if a greater than 40% reduction in nonHDL cholesterol is not achieved and
eGFR is 30 ml/min
Agree the use of higher doses with a renal specialist if eGFR is less than 30 ml/min

Hyperlipidaemia: management
In 2014 NICE updated their guidelines on lipid modification. This proved highly controversial as it
meant that we should be recommending statins to a significant proportion of the population over the
age of 60 years. Anyway, the key points of the new guidelines are summarised below.

Primary prevention - who and how to assess risk

A systematic strategy should be used to identify people aged over 40 years who are likely to be at
high risk of cardiovascular disease (CVD), defined as a 10-year risk of 10% or greater.
NICE recommend we use the QRISK2 CVD risk assessment tool for patients aged <= 84 years.
Patients >= 85 years are at high risk of CVD due to their age. QRISK2 should not be used in the
following situations as there are more specific guidelines for these patient groups:

type 1 diabetics

patients with an estimated glomerular filtration rate (eGFR) less than 60 ml/min and/or
albuminuria
patients with a history of familial hyperlipidaemia

NICE suggest QRISK2 may underestimate CVD risk in the following population groups:

people treated for HIV

people with serious mental health problems

people taking medicines that can cause dyslipidaemia such as antipsychotics, corticosteroids
or immunosuppressant drugs

people with autoimmune disorders/systemic inflammatory disorders such as systemic lupus

erythematosus

Measuring lipid levels

When measuring lipids both the total cholesterol and HDL should be checking to provide the most
accurate risk of CVD. A full lipid profile should also be checked (i.e. including triglycerides) before
starting a statin. The samples does not need to be fasting.
In the vast majority of patient the cholesterol measurements will be fed into the QRISK2 tool. If
however the patient's cholesterol is very high we should consider familial hyperlipidaemia. NICE
recommend the following that we should consider the possibility of familial hypercholesterolaemia
and investigate further if the total cholesterol concentration is > 7.5 mmol/l and there is a family
history of premature coronary heart disease. They also recommend referring people with a total
cholesterol > 9.0 mmol/l or a non-HDL cholesterol (i.e. LDL) of > 7.5 mmol/l even in the absence of a
first-degree family history of premature coronary heart disease.

Interpreting the QRISK2 result

Probably the headline changes in the 2014 guidelines was the new, lower cut-off of 10-year CVD
risk cut-off of 10%.
NICE now recommend we offer a statin to people with a QRISK2 10-year risk of >= 10%
Lifestyle factors are of course important and NICE recommend that we give patients the option of
having their CVD risk reassessed after a period of time before starting a statin.

Atorvastatin 20mg should be offered first-line.

Special situations
Type 1 diabetes mellitus

NICE recommend that we 'consider statin treatment for the primary prevention of CVD in all
adults with type 1 diabetes'
atorvastatin 20 mg should be offered if type 1 diabetics who are:
older than 40 years, or
have had diabetes for more than 10 years or
have established nephropathy or
have other CVD risk factors

Chronic kidney disease (CKD)

atorvastatin 20mg should be offered to patients with CKD

increase the dose if a greater than 40% reduction in non-HDL cholesterol is not achieved
and the eGFR > 30 ml/min. If the eGFR is < 30 ml/min a renal specialist should be consulted
before increasing the dose

Secondary prevention
All patients with CVD should be taking a statin in the absence of any contraindication.
Atorvastatin 80mg should be offered first-line.

Follow-up of people started on statins

NICE recommend we follow-up patients at 3 months

repeat a full lipid profile

if the non-HDL cholesterol has not fallen by at least 40% concordance and lifestyle changes
should be discussed with the patient
NICE recommend we consider increasing the dose of atorvastatin up to 80mg

Lifestyle modifications
These are in many ways predictable but NICE make a number of specific points:
Cardioprotective diet

total fat intake should be <= 30% of total energy intake

saturated fats should be <= 7% of total energy intake
intake of dietary cholesterol should be < 300 mg/day
saturated fats should be replaced by monounsaturated and polyunsaturated fats where
possible
replace saturated and monounsaturated fat intake with olive oil, rapeseed oil or spreads
based on these oils
choose wholegrain varieties of starchy food
reduce their intake of sugar and food products containing refined sugars including fructose
eat at least 5 portions of fruit and vegetables per day
eat at least 2 portions of fish per week, including a portion of oily fish
eat at least 4 to 5 portions of unsalted nuts, seeds and legumes per week

Physical activity

each week aim for at least 150 minutes of moderate intensity aerobic activity or 75 minutes
of vigorous intensity aerobic activity or a mix of moderate and vigorous aerobic activity
do musclestrengthening activities on 2 or more days a week that work all major muscle
groups (legs, hips, back, abdomen, chest, shoulders and arms) in line with national guidance
for the general population

Weight management

no specific advice is given, overweight patients should be managed in keeping with relevant
NICE guidance

Alcohol intake

again no specific advice, other than the general recommendation that males drink no more
than 3-4 units/day and females no more than 2-3 units/day

Smoking cessation

smokers should be encouraged to quit

Question 33 of 44

Next

Which of the following secondary causes of hyperlipidaemia result in predominantly

hypercholesterolaemia, as opposed to hypertriglyceridaemia?
A. Diabetes mellitus
B. Bendrofluazide
C. Nephrotic syndrome
D. Alcohol
E. Obesity
Next question

Hypercholesterolaemia rather than hypertriglyceridaemia: nephrotic syndrome, cholestasis, hypothyroidism

Hyperlipidaemia: secondary causes

Causes of predominantly hypertriglyceridaemia

diabetes mellitus (types 1 and 2)

obesity
alcohol
chronic renal failure
drugs: thiazides, non-selective beta-blockers, unopposed oestrogen
liver disease

Causes of predominantly hypercholesterolaemia

nephrotic syndrome

cholestasis
hypothyroidism

Next

Question 34 of 44

A 29-year-old man presents concerned about his weight. His body mass index is 38 kg/m^2. Which
one of the following best describes his weight?
A. Morbidly obese (Obese III)
B. Normal
C. Overweight
D. Clinically obese (Obese II)
E. Obese (Obese I)
Next question

Body mass index

Body mass index (BMI) is calculated by dividing the weight (in kilograms) by the height (in metres)
squared

BMI

Old classification

NICE classification

< 18.5

Underweight

Underweight

18.5 - 24.9

Normal

Normal

25 - 29.9

Overweight

Overweight

30 - 34.9

Obese

Obese I

35 - 39.9

Clinically obese

Obese II

> 40

Morbidly obese

Obese III

Question 35 of 44

Next

You review a 21-year-old woman who has recently been diagnosed with type 1 diabetes mellitus.
She was admitted three months ago with vomiting, abdominal pain and weight loss and was found to
hyperglycaemic. A diagnosis of type 1 diabetes mellitus was made. She was started on insulin.
Recent bloods show the following:

Na+
140 mmol/l
+
K
3.8 mmol/l
Urea
3.4 mmol/l
Creatinine 72 mol/l

Total cholesterol 5.1 mmol/l

HDL cholesterol 1.0 mmol/l
LDL cholesterol 2.9 mmol/l
Triglyceride
1.7 mmol/l
Urine dip: No protein or blood
She has no family history of note and her body mass index is 20.5 kg/m. What is the most
appropriate management with regards to lipid modification?
A. Start atorvastatin 10mg on
B. Start atorvastatin 20mg on
C. Start atorvastatin 40mg on
D. Perform a QRISK2 assessment
E. Reassure her that lipid modification therapy is not required at this stage

Next question
NICE specifically state that we should not use QRISK2 for type 1 diabetics. Instead, the following
criteria are used:

older than 40 years, or

have had diabetes for more than 10 years or

have established nephropathy or
have other CVD risk factors

None of these apply in this case.

Hyperlipidaemia: management
In 2014 NICE updated their guidelines on lipid modification. This proved highly controversial as it
meant that we should be recommending statins to a significant proportion of the population over the
age of 60 years. Anyway, the key points of the new guidelines are summarised below.

Primary prevention - who and how to assess risk

A systematic strategy should be used to identify people aged over 40 years who are likely to be at
high risk of cardiovascular disease (CVD), defined as a 10-year risk of 10% or greater.
NICE recommend we use the QRISK2 CVD risk assessment tool for patients aged <= 84 years.
Patients >= 85 years are at high risk of CVD due to their age. QRISK2 should not be used in the
following situations as there are more specific guidelines for these patient groups:

type 1 diabetics
patients with an estimated glomerular filtration rate (eGFR) less than 60 ml/min and/or
albuminuria
patients with a history of familial hyperlipidaemia

NICE suggest QRISK2 may underestimate CVD risk in the following population groups:

people treated for HIV

people with serious mental health problems
people taking medicines that can cause dyslipidaemia such as antipsychotics, corticosteroids
or immunosuppressant drugs

people with autoimmune disorders/systemic inflammatory disorders such as systemic lupus

erythematosus

Measuring lipid levels

When measuring lipids both the total cholesterol and HDL should be checking to provide the most
accurate risk of CVD. A full lipid profile should also be checked (i.e. including triglycerides) before
starting a statin. The samples does not need to be fasting.
In the vast majority of patient the cholesterol measurements will be fed into the QRISK2 tool. If
however the patient's cholesterol is very high we should consider familial hyperlipidaemia. NICE
recommend the following that we should consider the possibility of familial hypercholesterolaemia
and investigate further if the total cholesterol concentration is > 7.5 mmol/l and there is a family
history of premature coronary heart disease. They also recommend referring people with a total
cholesterol > 9.0 mmol/l or a non-HDL cholesterol (i.e. LDL) of > 7.5 mmol/l even in the absence of a
first-degree family history of premature coronary heart disease.

Interpreting the QRISK2 result

Probably the headline changes in the 2014 guidelines was the new, lower cut-off of 10-year CVD
risk cut-off of 10%.
NICE now recommend we offer a statin to people with a QRISK2 10-year risk of >= 10%
Lifestyle factors are of course important and NICE recommend that we give patients the option of
having their CVD risk reassessed after a period of time before starting a statin.
Atorvastatin 20mg should be offered first-line.

Special situations
Type 1 diabetes mellitus

NICE recommend that we 'consider statin treatment for the primary prevention of CVD in all
adults with type 1 diabetes'
atorvastatin 20 mg should be offered if type 1 diabetics who are:
older than 40 years, or

have had diabetes for more than 10 years or

have established nephropathy or
have other CVD risk factors

Chronic kidney disease (CKD)

atorvastatin 20mg should be offered to patients with CKD

increase the dose if a greater than 40% reduction in non-HDL cholesterol is not achieved
and the eGFR > 30 ml/min. If the eGFR is < 30 ml/min a renal specialist should be consulted
before increasing the dose

Secondary prevention
All patients with CVD should be taking a statin in the absence of any contraindication.
Atorvastatin 80mg should be offered first-line.

Follow-up of people started on statins

NICE recommend we follow-up patients at 3 months

repeat a full lipid profile

if the non-HDL cholesterol has not fallen by at least 40% concordance and lifestyle changes
should be discussed with the patient
NICE recommend we consider increasing the dose of atorvastatin up to 80mg

Lifestyle modifications
These are in many ways predictable but NICE make a number of specific points:
Cardioprotective diet

total fat intake should be <= 30% of total energy intake

saturated fats should be <= 7% of total energy intake
intake of dietary cholesterol should be < 300 mg/day
saturated fats should be replaced by monounsaturated and polyunsaturated fats where
possible

replace saturated and monounsaturated fat intake with olive oil, rapeseed oil or spreads
based on these oils
choose wholegrain varieties of starchy food
reduce their intake of sugar and food products containing refined sugars including fructose
eat at least 5 portions of fruit and vegetables per day
eat at least 2 portions of fish per week, including a portion of oily fish
eat at least 4 to 5 portions of unsalted nuts, seeds and legumes per week

Physical activity

each week aim for at least 150 minutes of moderate intensity aerobic activity or 75 minutes
of vigorous intensity aerobic activity or a mix of moderate and vigorous aerobic activity
do musclestrengthening activities on 2 or more days a week that work all major muscle
groups (legs, hips, back, abdomen, chest, shoulders and arms) in line with national guidance
for the general population

Weight management

no specific advice is given, overweight patients should be managed in keeping with relevant
NICE guidance

Alcohol intake

again no specific advice, other than the general recommendation that males drink no more
than 3-4 units/day and females no more than 2-3 units/day

Smoking cessation

smokers should be encouraged to quit

Question 36 of 44
A rise in alkaline phosphatase can be caused by each one of the following except:

Next

A. Pregnancy
B. Paget's disease
C. Healing bone fractures
D. Osteomalacia
E. Hypoparathyroidism
Next question

Alkaline phosphatase
Causes of raised alkaline phosphatase (ALP)

liver: cholestasis, hepatitis, fatty liver, neoplasia

Paget's
osteomalacia
bone metastases
hyperparathyroidism
renal failure
physiological: pregnancy, growing children, healing fractures

The table below splits the causes according to the calcium level

Raised ALP and raised calcium

Raised ALP and low calcium

Bone metastases
Hyperparathyroidism

Osteomalacia
Renal failure

Question 37 of 44
You get phoned about a patient's potassium result:

Next

K+

6.3 mmol/l

Which one of the following would not explain this result?

A. Delay in transport to the laboratory
B. Losartan therapy
C. Addison's disease
D. Acute renal failure
E. Conn's syndrome
Next question
Conn's syndrome is associated with hypokalaemia.
Hyperkalaemia
Plasma potassium levels are regulated by a number of factors including aldosterone, acid-base
balance and insulin levels. Metabolic acidosis is associated with hyperkalaemia as hydrogen and
potassium ions compete with each other for exchange with sodium ions across cell membranes and
in the distal tubule. ECG changes seen in hyperkalaemia include tall-tented T waves, small P waves,
widened QRS leading to a sinusoidal pattern and asystole
Causes of hyperkalaemia:

acute renal failure

drugs*: potassium sparing diuretics, ACE inhibitors, angiotensin 2 receptor blockers,
spironolactone, ciclosporin, heparin**
metabolic acidosis
Addison's
rhabdomyolysis
massive blood transfusion

Foods that are high in potassium:

salt substitutes (i.e. Contain potassium rather than sodium)

bananas, oranges, kiwi fruit, avocado, spinach, tomatoes

*beta-blockers interfere with potassium transport into cells and can potentially cause hyperkalaemia
in renal failure patients - remember beta-agonists, e.g. Salbutamol, are sometimes used as
emergency treatment
**both unfractionated and low-molecular weight heparin can cause hyperkalaemia. This is thought to
be caused by inhibition of aldosterone secretion

3/3

Question 38-40 of 44

Theme: Vitamin deficiency

A. Vitamin A
B. Thiamine
C. Niacin
D. Pyridoxine
E. Folic acid
F. Vitamin B12
G. Vitamin C
H. Vitamin D
I. Vitamin E
J. Vitamin K
For each one of the following scenarios select the vitamin which may cause these features if
deficient:

38.

Wernicke-Korsakoff syndrome
Thiamine

Next

39.

Neural tube defects

Folic acid

40.

Haemorrhagic disease of the newborn

Vitamin K

Next question

Vitamin deficiency

The table below summarises vitamin deficiency states

Vitamin

Chemical name

Deficiency state

Retinoids

Night-blindness (nyctalopia)

B1

Thiamine

Beriberi

B3

Niacin

polyneuropathy, Wernicke-Korsakoff syndrome

heart failure

Pellagra

dermatitis
diarrhoea
dementia

B6

Pyridoxine

Anaemia, irritability, seizures

B7

Biotin

Dermatitis, seborrhoea

B9

Folic acid

Megaloblastic anaemia, deficiency during pregnancy - neural tube defects

B12

Cyanocobalamin

Megaloblastic anaemia, peripheral neuropathy

Ascorbic acid

Scurvy

gingivitis
bleeding

Ergocalciferol,
cholecalciferol

Rickets, osteomalacia

Tocopherol, tocotrienol

Mild haemolytic anaemia in newborn infants, ataxia, peripheral

neuropathy

Naphthoquinone

Haemorrhagic disease of the newborn, bleeding diathesis

Question 41 of 44

Next

A 33-year-old woman who is known to have familial hypercholesterolaemia comes for review. She is
planning to have children and asks for advice regarding medication as she currently takes
atorvastatin 80mg on. What is the most appropriate advice?
A. Switch to atorvastatin 10mg
B. Continue current drug at same dose
C. Stop atorvastatin before trying to conceive
D. Switch to ezetimibe
E. Switch to simvastatin 40mg
Next question
Statins should be discontinued in women 3 months before conception due to the risk of congenital
defects
Familial hypercholesterolaemia

Familial hypercholesterolaemia (FH) is an autosomal dominant condition that is thought to affect

around 1 in 500 people. It results in high levels of LDL-cholesterol which, if untreated, may cause
early cardiovascular disease (CVD). FH is caused by mutations in the gene which encodes the LDLreceptor protein.
Clinical diagnosis is now based on the Simon Broome criteria:

in adults total cholesterol (TC) > 7.5 mmol/l and LDL-C > 4.9 mmol/l or children TC > 6.7
mmol/l and LDL-C > 4.0 mmol/l, plus:
for definite FH: tendon xanthoma in patients or 1st or 2nd degree relatives or DNA-based
evidence of FH
for possible FH: family history of myocardial infarction below age 50 years in 2nd degree
relative, below age 60 in 1st degree relative, or a family history of raised cholesterol levels

Management

the use of CVD risk estimation using standard tables is not appropriate in FH as they do not
accurately reflect the risk of CVD
referral to a specialist lipid clinic is usually required
the maximum dose of potent statins are usually required
first-degree relatives have a 50% chance of having the disorder and should therefore be
offered screening. This includes children who should be screened by the age of 10 years if
there is one affected parent
statins should be discontinued in women 3 months before conception due to the risk of
congenital defects

Question 42 of 44

Next

A 52-year-old woman is started on atorvastatin 20mg as her QRISK2 score is calculated at 13%.
She is a current smoker and is treated for hypertension with ramipril 5mg od. She is keen to lower
her risk and asks whether she should join a gym. Which one of the following best represents NICE
advice with regards to physical activity?

A. Undertake moderate exercise that will cause an increase in heart rate at least 3
times a week
B. At least 300 minutes of moderate intensity aerobic activity or 150 minutes of
vigorous intensity aerobic activity
C. At least 150 minutes of moderate intensity aerobic activity or 75 minutes of
vigorous intensity aerobic activity
D. At least 100 minutes of moderate intensity aerobic activity or 50 minutes of
vigorous intensity aerobic activity
E.
At least 50 minutes of moderate intensity aerobic activity or 25 minutes of
vigorous intensity aerobic activity
Next question

Hyperlipidaemia: management
In 2014 NICE updated their guidelines on lipid modification. This proved highly controversial as it
meant that we should be recommending statins to a significant proportion of the population over the
age of 60 years. Anyway, the key points of the new guidelines are summarised below.

Primary prevention - who and how to assess risk

A systematic strategy should be used to identify people aged over 40 years who are likely to be at
high risk of cardiovascular disease (CVD), defined as a 10-year risk of 10% or greater.
NICE recommend we use the QRISK2 CVD risk assessment tool for patients aged <= 84 years.
Patients >= 85 years are at high risk of CVD due to their age. QRISK2 should not be used in the
following situations as there are more specific guidelines for these patient groups:

type 1 diabetics
patients with an estimated glomerular filtration rate (eGFR) less than 60 ml/min and/or
albuminuria
patients with a history of familial hyperlipidaemia

NICE suggest QRISK2 may underestimate CVD risk in the following population groups:

people treated for HIV

people with serious mental health problems

people taking medicines that can cause dyslipidaemia such as antipsychotics, corticosteroids
or immunosuppressant drugs
people with autoimmune disorders/systemic inflammatory disorders such as systemic lupus
erythematosus

Measuring lipid levels

When measuring lipids both the total cholesterol and HDL should be checking to provide the most
accurate risk of CVD. A full lipid profile should also be checked (i.e. including triglycerides) before
starting a statin. The samples does not need to be fasting.
In the vast majority of patient the cholesterol measurements will be fed into the QRISK2 tool. If
however the patient's cholesterol is very high we should consider familial hyperlipidaemia. NICE
recommend the following that we should consider the possibility of familial hypercholesterolaemia
and investigate further if the total cholesterol concentration is > 7.5 mmol/l and there is a family
history of premature coronary heart disease. They also recommend referring people with a total
cholesterol > 9.0 mmol/l or a non-HDL cholesterol (i.e. LDL) of > 7.5 mmol/l even in the absence of a
first-degree family history of premature coronary heart disease.

Interpreting the QRISK2 result

Probably the headline changes in the 2014 guidelines was the new, lower cut-off of 10-year CVD
risk cut-off of 10%.
NICE now recommend we offer a statin to people with a QRISK2 10-year risk of >= 10%
Lifestyle factors are of course important and NICE recommend that we give patients the option of
having their CVD risk reassessed after a period of time before starting a statin.
Atorvastatin 20mg should be offered first-line.

Special situations
Type 1 diabetes mellitus

NICE recommend that we 'consider statin treatment for the primary prevention of CVD in all
adults with type 1 diabetes'
atorvastatin 20 mg should be offered if type 1 diabetics who are:
older than 40 years, or
have had diabetes for more than 10 years or
have established nephropathy or
have other CVD risk factors

Chronic kidney disease (CKD)

atorvastatin 20mg should be offered to patients with CKD

increase the dose if a greater than 40% reduction in non-HDL cholesterol is not achieved
and the eGFR > 30 ml/min. If the eGFR is < 30 ml/min a renal specialist should be consulted
before increasing the dose

Secondary prevention
All patients with CVD should be taking a statin in the absence of any contraindication.
Atorvastatin 80mg should be offered first-line.

Follow-up of people started on statins

NICE recommend we follow-up patients at 3 months

repeat a full lipid profile

if the non-HDL cholesterol has not fallen by at least 40% concordance and lifestyle changes
should be discussed with the patient
NICE recommend we consider increasing the dose of atorvastatin up to 80mg

Lifestyle modifications
These are in many ways predictable but NICE make a number of specific points:
Cardioprotective diet

total fat intake should be <= 30% of total energy intake

saturated fats should be <= 7% of total energy intake

intake of dietary cholesterol should be < 300 mg/day

saturated fats should be replaced by monounsaturated and polyunsaturated fats where
possible
replace saturated and monounsaturated fat intake with olive oil, rapeseed oil or spreads
based on these oils
choose wholegrain varieties of starchy food
reduce their intake of sugar and food products containing refined sugars including fructose
eat at least 5 portions of fruit and vegetables per day
eat at least 2 portions of fish per week, including a portion of oily fish
eat at least 4 to 5 portions of unsalted nuts, seeds and legumes per week

Physical activity

each week aim for at least 150 minutes of moderate intensity aerobic activity or 75 minutes
of vigorous intensity aerobic activity or a mix of moderate and vigorous aerobic activity
do musclestrengthening activities on 2 or more days a week that work all major muscle
groups (legs, hips, back, abdomen, chest, shoulders and arms) in line with national guidance
for the general population

Weight management

no specific advice is given, overweight patients should be managed in keeping with relevant
NICE guidance

Alcohol intake

again no specific advice, other than the general recommendation that males drink no more
than 3-4 units/day and females no more than 2-3 units/day

Smoking cessation

smokers should be encouraged to quit

Question 43 of 44

Next

A 52-year-old has a fasting lipid profile checked as part of an annual occupational health check.
Combined with his blood pressure and current smoking status his 10-year risk of cardiovascular
disease is calculated to be 23% percent. Following appropriate counselling he chooses to start
atorvastatin 20mg. He is followed up 3 months later when a full lipid profile is repeated. What should
his target be?
A. A greater than 40% reduction in non-HDL cholesterol
B. Total cholesterol < 5 mmol/l
C. Target cholesterol is inappropriate in this situation
D. Total cholesterol < 4 mmol/l
E. Total cholesterol:HDL ratio < 4
Next question

In the primary prevention of CVD using statins aim for a reduction in non-HDL cholesterol of > 40%

Hyperlipidaemia: management
In 2014 NICE updated their guidelines on lipid modification. This proved highly controversial as it
meant that we should be recommending statins to a significant proportion of the population over the
age of 60 years. Anyway, the key points of the new guidelines are summarised below.

Primary prevention - who and how to assess risk

A systematic strategy should be used to identify people aged over 40 years who are likely to be at
high risk of cardiovascular disease (CVD), defined as a 10-year risk of 10% or greater.
NICE recommend we use the QRISK2 CVD risk assessment tool for patients aged <= 84 years.
Patients >= 85 years are at high risk of CVD due to their age. QRISK2 should not be used in the
following situations as there are more specific guidelines for these patient groups:

type 1 diabetics

patients with an estimated glomerular filtration rate (eGFR) less than 60 ml/min and/or
albuminuria
patients with a history of familial hyperlipidaemia

NICE suggest QRISK2 may underestimate CVD risk in the following population groups:

people treated for HIV

people with serious mental health problems

people taking medicines that can cause dyslipidaemia such as antipsychotics, corticosteroids

or immunosuppressant drugs
people with autoimmune disorders/systemic inflammatory disorders such as systemic lupus
erythematosus

Measuring lipid levels

When measuring lipids both the total cholesterol and HDL should be checking to provide the most
accurate risk of CVD. A full lipid profile should also be checked (i.e. including triglycerides) before
starting a statin. The samples does not need to be fasting.
In the vast majority of patient the cholesterol measurements will be fed into the QRISK2 tool. If
however the patient's cholesterol is very high we should consider familial hyperlipidaemia. NICE
recommend the following that we should consider the possibility of familial hypercholesterolaemia
and investigate further if the total cholesterol concentration is > 7.5 mmol/l and there is a family
history of premature coronary heart disease. They also recommend referring people with a total
cholesterol > 9.0 mmol/l or a non-HDL cholesterol (i.e. LDL) of > 7.5 mmol/l even in the absence of a
first-degree family history of premature coronary heart disease.

Interpreting the QRISK2 result

Probably the headline changes in the 2014 guidelines was the new, lower cut-off of 10-year CVD
risk cut-off of 10%.
NICE now recommend we offer a statin to people with a QRISK2 10-year risk of >= 10%
Lifestyle factors are of course important and NICE recommend that we give patients the option of
having their CVD risk reassessed after a period of time before starting a statin.

Atorvastatin 20mg should be offered first-line.

Special situations
Type 1 diabetes mellitus

NICE recommend that we 'consider statin treatment for the primary prevention of CVD in all
adults with type 1 diabetes'
atorvastatin 20 mg should be offered if type 1 diabetics who are:
older than 40 years, or
have had diabetes for more than 10 years or
have established nephropathy or
have other CVD risk factors

Chronic kidney disease (CKD)

atorvastatin 20mg should be offered to patients with CKD

increase the dose if a greater than 40% reduction in non-HDL cholesterol is not achieved
and the eGFR > 30 ml/min. If the eGFR is < 30 ml/min a renal specialist should be consulted
before increasing the dose

Secondary prevention
All patients with CVD should be taking a statin in the absence of any contraindication.
Atorvastatin 80mg should be offered first-line.

Follow-up of people started on statins

NICE recommend we follow-up patients at 3 months

repeat a full lipid profile

if the non-HDL cholesterol has not fallen by at least 40% concordance and lifestyle changes
should be discussed with the patient
NICE recommend we consider increasing the dose of atorvastatin up to 80mg

Lifestyle modifications
These are in many ways predictable but NICE make a number of specific points:
Cardioprotective diet

total fat intake should be <= 30% of total energy intake

saturated fats should be <= 7% of total energy intake
intake of dietary cholesterol should be < 300 mg/day
saturated fats should be replaced by monounsaturated and polyunsaturated fats where
possible
replace saturated and monounsaturated fat intake with olive oil, rapeseed oil or spreads
based on these oils
choose wholegrain varieties of starchy food
reduce their intake of sugar and food products containing refined sugars including fructose
eat at least 5 portions of fruit and vegetables per day
eat at least 2 portions of fish per week, including a portion of oily fish
eat at least 4 to 5 portions of unsalted nuts, seeds and legumes per week

Physical activity

each week aim for at least 150 minutes of moderate intensity aerobic activity or 75 minutes
of vigorous intensity aerobic activity or a mix of moderate and vigorous aerobic activity
do musclestrengthening activities on 2 or more days a week that work all major muscle
groups (legs, hips, back, abdomen, chest, shoulders and arms) in line with national guidance
for the general population

Weight management

no specific advice is given, overweight patients should be managed in keeping with relevant
NICE guidance

Alcohol intake

again no specific advice, other than the general recommendation that males drink no more
than 3-4 units/day and females no more than 2-3 units/day

Smoking cessation

smokers should be encouraged to quit

Question 44 of 44
A 58-year-old woman complains of aches and pains in her bones. Her family have noticed she is
generally weak and lethargic. A series of blood tests are requested:
Calcium

2.04 mmol/l

Albumin

39 g/l

Phosphate

0.63 mmol/l

Alkaline phosphatase 271 U/l

Vitamin D3

15 nmol/l (75-200 nmol/l)

Parathyroid hormone 10.8 pmol/l (0.8 - 8.5 pmol/l)

What is the most appropriate management?

A. Arrange a liver ultrasound
B. Refer for a technetium-MIBI subtraction scan
C. Arrange a DEXA scan
D. Arrange serum electrophoresis and a skeletal survery
E. Start vitamin D3 supplementation

The low calcium, phosphate and vitamin D levels combined with a raised alkaline phosphatase and
parathyroid hormone level is entirely consistent with osteomalacia, or vitamin D deficiency. The
treatment of choice is therefore vitamin D3 supplementation.
Remember blood values are normal in osteoporosis. Myeloma ('Arrange serum electrophoresis and
a skeletal survery') and primary hyperparathyroidism ('Refer for a technetium-MIBI subtraction scan')
are associated with hyper- rather than hypocalcaemia.

Osteomalacia
Basics

normal bony tissue but decreased mineral content

rickets if when growing
osteomalacia if after epiphysis fusion

Types

vitamin D deficiency e.g. malabsorption, lack of sunlight, diet

renal failure
drug induced e.g. anticonvulsants
vitamin D resistant; inherited
liver disease, e.g. cirrhosis

Features

rickets: knock-knee, bow leg, features of hypocalcaemia

osteomalacia: bone pain, fractures, muscle tenderness, proximal myopathy

Investigation

low calcium, phosphate, 25(OH) vitamin D

raised alkaline phosphatase
x-ray: children - cupped, ragged metaphyseal surfaces; adults - translucent bands (Looser's
zones or pseudofractures)

Treatment

calcium with vitamin D tablets