Set 1: For each patient, select the most appropriate antihypertensive option.
A. Amlodipine
B. Ramipril
C. Indapamide
D. Spironolactone
E. Bisoprolol
F. Doxazosin
G. Verapamil
H. Losartan
1. A 52-year-old man of Black African family background has newly diagnosed stage 1 hypertension. He has type 2 diabetes and a QRISK3 score of 15%. His eGFR is 82 mL/min/1.73 m² and potassium is 4.3 mmol/L. He has no albuminuria and no previous antihypertensive intolerance.
Which option is most appropriate?
2. A 68-year-old woman is taking ramipril 10 mg once daily, amlodipine 10 mg once daily and indapamide 2.5 mg once daily. Her clinic blood pressure remains 158/92 mmHg. Home readings confirm poor control. Her eGFR is 58 mL/min/1.73 m² and potassium is 4.2 mmol/L.
Which option is most appropriate to consider adding?
Set 2: For each patient, select the most appropriate stroke prevention option.
A. Aspirin 75 mg once daily
B. Warfarin
C. Clopidogrel
D. No antithrombotic treatment
E. Enoxaparin long term
F. Apixaban
G. Dual antiplatelet therapy
H. Edoxaban
3. A 73-year-old woman has newly diagnosed atrial fibrillation. She has hypertension, type 2 diabetes and previous TIA. Her eGFR is 64 mL/min/1.73 m². She has no mechanical valve, no moderate-to-severe mitral stenosis and no active bleeding.
Which option is most appropriate?
4. A 61-year-old man has atrial fibrillation and a mechanical mitral valve replacement. His renal function is normal. He asks whether he can switch to a DOAC because his friend takes apixaban.
Which option is most appropriate?
Set 3: For each patient, select the most appropriate immediate or early management option.
A. Omeprazole and antacid therapy
B. Ibuprofen and safety-netting
C. Reassurance and lifestyle advice only
D. Oral antibiotics
E. GTN spray only and routine GP review
F. Delay assessment until troponin can be checked by the GP
G. Aspirin 300 mg and emergency transfer
H. Stop all antiplatelets
5. A 64-year-old man presents to the pharmacy with 40 minutes of central chest pressure radiating to the jaw. He is pale and nauseated. He used his wife’s GTN spray with partial relief, but the pain has returned. He has no aspirin allergy.
Which option is most appropriate?
6. A 59-year-old woman had predictable exertional angina for 2 years. Over the last 24 hours she has had chest tightness at rest, lasting 15–20 minutes each time. GTN gives incomplete relief. She is currently pain-free but anxious.
Which option is most appropriate?
Set 4: For each patient, select the most appropriate medicine-related intervention.
A. Start furosemide
B. Stop all heart failure medicines
C. Start dapagliflozin
D. Start bisoprolol
E. Start ramipril
F. Start verapamil
G. Start ibuprofen
H. Start spironolactone
7. A 72-year-old man with heart failure with reduced ejection fraction is taking ramipril and bisoprolol at tolerated doses. He remains breathless on exertion but has no ankle swelling or pulmonary oedema. His eGFR is 68 mL/min/1.73 m² and potassium is 4.4 mmol/L. He is not diabetic.
Which option is most appropriate to consider adding for heart failure benefit?
8. A 77-year-old woman with chronic heart failure presents with worsening orthopnoea, bilateral ankle swelling and raised JVP. She has basal crackles and has gained 3 kg over 1 week.
Which option is most appropriate for symptomatic relief?
Set 5: For each patient, select the most appropriate monitoring or safety action.
A. Check peak flow only
B. Check INR urgently
C. Check creatine kinase and renal function urgently
D. No monitoring is needed
E. Check digoxin level, renal function, electrolytes and ECG
F. Check HbA1c only
G. Check vitamin B12 only
H. Check U&Es and renal function soon after initiation or dose increase
9. A 79-year-old woman taking digoxin develops nausea, confusion and yellow-green visual disturbance. Her pulse is 48 bpm. She recently started bendroflumethiazide and her renal function has worsened.
Which option is most appropriate?
10. A 66-year-old man taking ramipril for hypertension is prescribed spironolactone for resistant hypertension. His baseline eGFR is 54 mL/min/1.73 m² and potassium is 4.8 mmol/L.
Which option is most appropriate?
Set 6: For each patient, select the most clinically important interaction or safety concern.
A. Reduced efficacy of clopidogrel with omeprazole
B. Increased bleeding risk from DOAC and NSAID
C. Hyperkalaemia from ACE inhibitor, potassium-sparing diuretic and trimethoprim
D. Lithium toxicity precipitated by ACE inhibitor
E. Bradycardia from beta-blocker and verapamil combination
F. Severe hypotension from nitrate and PDE5 inhibitor combination
G. Rhabdomyolysis risk from simvastatin and clarithromycin
H. Reduced anticoagulant effect from missed DOAC doses
11. A 70-year-old man with atrial fibrillation takes apixaban. He asks to buy naproxen for knee pain. He has a previous history of peptic ulcer disease and takes no gastroprotection.
Which option is most relevant?
12. A 62-year-old man uses GTN spray for angina and asks to buy sildenafil. His angina is usually stable, but he used GTN twice last week.
Which option is most relevant?
Set 7: For each patient, select the most appropriate lipid-management option.
A. No lipid-lowering therapy because age is over 70
B. Fenofibrate first-line for secondary prevention
C. Atorvastatin 80 mg once daily
D. Simvastatin 80 mg first-line
E. Omega-3 capsules as routine secondary prevention
F. Temporarily withhold simvastatin and clarify antibiotic/statin plan
G. Atorvastatin 20 mg once daily
H. Stop statin because cholesterol is now controlled
13. A 57-year-old man has no previous cardiovascular event. His QRISK3 score is 13%. Lifestyle measures have been discussed. Liver function is normal and he has no statin contraindication.
Which option is most appropriate?
14. A 69-year-old woman taking simvastatin 40 mg once daily is prescribed clarithromycin for pneumonia. She has normal renal function but has previously had statin-associated muscle symptoms.
Which option is most appropriate?
Set 8: For each patient, select the most appropriate option.
A. Ivabradine
B. Isosorbide mononitrate
C. Amlodipine
D. Aspirin 300 mg and emergency transfer
E. Verapamil plus bisoprolol
F. Bisoprolol
G. Verapamil
H. GTN sublingual spray
15. A 58-year-old man has newly diagnosed stable angina. He has predictable chest tightness walking uphill and wants a medicine to treat acute episodes quickly. He is also being started on secondary prevention.
Which option is most appropriate for rapid symptom relief?
16. A 71-year-old man with stable angina is taking bisoprolol 10 mg once daily. His heart rate is 52 bpm and blood pressure is 150/84 mmHg. He still has exertional angina twice weekly. He has no ankle swelling.
Which option is most appropriate to consider adding?
Set 9: For each patient, select the most appropriate pharmacist action.
A. Add aspirin
B. Switch DOAC to clopidogrel
C. Continue anticoagulant unchanged
D. Give vitamin C
E. Stop anticoagulation permanently
F. Arrange urgent assessment for possible major bleeding
G. Double the next dose
H. Withhold warfarin and follow high-INR protocol
17. A 76-year-old woman taking rivaroxaban reports black stools, dizziness and shortness of breath. Her blood pressure is 92/58 mmHg. She has recently started ibuprofen.
Which option is most appropriate?
18. A 73-year-old man taking warfarin has an INR of 7.8 after starting metronidazole. He has no bleeding, no recent fall and is clinically stable.
Which option is most appropriate?
Set 10: For each patient, select the most appropriate medicine-related recommendation.
A. Warfarin for all patients after MI
B. NSAID for routine post-MI chest discomfort
C. Stop all cardiovascular medicines once pain resolves
D. Clopidogrel only, no statin
E. Antibiotics for 12 months
F. Aspirin only
G. GTN only
H. High-intensity statin, antiplatelet therapy, ACE inhibitor and beta-blocker if appropriate
19. A 60-year-old man is discharged after NSTEMI. He has no contraindications to standard secondary prevention medicines. He is not on any regular cardiovascular medicines before admission.
Which option best reflects appropriate discharge medicine planning?
20. A 67-year-old woman had an MI 2 weeks ago. She asks whether she can stop her atorvastatin because her cholesterol was “not that high” before admission.
Which option is most appropriate?
Cardiovascular Questions
Answers and Rationale
1. H
In hypertension with type 2 diabetes, an ACE inhibitor or ARB is appropriate. In adults of Black African or African-Caribbean family background with type 2 diabetes, an ARB may be preferred over an ACE inhibitor, making losartan the best answer here.
2. D
This patient has resistant hypertension despite ACE inhibitor, calcium-channel blocker and thiazide-like diuretic therapy. With potassium below 4.5 mmol/L and acceptable renal function, low-dose spironolactone is an appropriate step 4 option with monitoring.
3. F
This patient has atrial fibrillation with multiple stroke risk factors and no contraindication to DOAC therapy. A DOAC such as apixaban is appropriate for stroke prevention in non-valvular AF.
4. B
Mechanical heart valves require warfarin anticoagulation. DOACs are not appropriate for mechanical valves, even if renal function is normal.
5. G
Ongoing central chest pain with radiation, nausea and pallor suggests acute coronary syndrome. Aspirin 300 mg should be given if not contraindicated and emergency transfer arranged.
6. G
Rest pain, longer duration and incomplete GTN response suggest unstable angina or ACS, even if she is pain-free at the moment. This needs emergency assessment rather than routine angina review.
7. C
SGLT2 inhibitors such as dapagliflozin have benefit in heart failure with reduced ejection fraction, including in people without diabetes. Renal function and sick-day counselling should be considered.
8. A
Orthopnoea, raised JVP, crackles, ankle swelling and rapid weight gain indicate fluid overload. A loop diuretic such as furosemide is appropriate for symptom relief.
9. E
Nausea, confusion, visual disturbance and bradycardia suggest digoxin toxicity. Worsening renal function and diuretic-induced electrolyte disturbance increase risk, so ECG, renal function, electrolytes and digoxin level are needed.
10. H
Adding spironolactone to an ACE inhibitor increases hyperkalaemia and renal impairment risk. U&Es and renal function should be checked soon after initiation and dose changes.
11. B
A DOAC plus NSAID increases bleeding risk, especially in an older patient with previous peptic ulcer disease. Naproxen should be avoided or discussed carefully with consideration of safer alternatives.
12. F
PDE5 inhibitors such as sildenafil must not be used with nitrates such as GTN due to risk of severe hypotension. The patient should be referred for safer erectile dysfunction management.
13. G
For primary prevention where QRISK3 is 10% or greater, atorvastatin 20 mg once daily is commonly offered after discussion of benefits, risks and lifestyle measures.
14. F
Clarithromycin can increase simvastatin exposure and risk of myopathy or rhabdomyolysis. With previous muscle symptoms, the statin/antibiotic plan should be clarified and simvastatin may need temporary withholding.
15. H
GTN sublingual spray provides rapid relief of acute angina symptoms and can be used before predictable exertion. It should be supplied with counselling on hypotension and emergency action.
16. C
The patient is already bradycardic on maximum beta-blocker therapy. Adding amlodipine can improve angina and blood pressure without further rate limitation. Verapamil with a beta-blocker would increase bradycardia and heart block risk.
17. F
Black stools, dizziness, breathlessness and hypotension suggest significant gastrointestinal bleeding. Rivaroxaban plus ibuprofen increases bleeding risk, so urgent assessment is needed.
18. H
A high INR after metronidazole suggests increased warfarin effect. Warfarin should be withheld and local high-INR guidance followed, considering vitamin K depending on bleeding risk and protocol.
19. H
After NSTEMI, standard secondary prevention usually includes high-intensity statin therapy, antiplatelet therapy, ACE inhibitor and beta-blocker where appropriate. Individual contraindications and monitoring must be considered.
20. H
High-intensity statin therapy after MI is for secondary prevention and risk reduction, not only for treating a high baseline cholesterol result. Stopping it because cholesterol was “not that high” would be inappropriate without clinical review.
Here are 20 extended matching questions designed to mimic the GPHC exam itself. At the bottom of the page you will find answers and rationale for each question.