1. A 53-year-old man has newly diagnosed hypertension confirmed by ambulatory blood pressure monitoring. His average daytime blood pressure is 152/94 mmHg. He has no diabetes, chronic kidney disease or heart failure. He is not of Black African or African-Caribbean family origin and has normal renal function.
Which ONE of the following is the most appropriate first-line antihypertensive treatment?
A. Amlodipine.
B. Doxazosin.
C. Ramipril.
D. Spironolactone.
E. Furosemide.
2. A 79-year-old woman with atrial fibrillation is prescribed apixaban. At review, her renal function has declined significantly and she has lost weight following a recent illness.
Which ONE of the following is the most appropriate pharmacist action?
A. Stop apixaban permanently.
B. Switch to aspirin.
C. Increase the apixaban dose.
D. Start routine INR monitoring.
E. Check whether the apixaban dose remains appropriate based on renal function, age and weight.
3. A 68-year-old man with heart failure with reduced ejection fraction is taking ramipril, bisoprolol and furosemide. His symptoms remain stable, renal function is acceptable and potassium is 4.5 mmol/L.
Which ONE of the following medicine classes should be considered as part of disease-modifying therapy?
A. Mineralocorticoid receptor antagonist.
B. Macrolide antibiotic.
C. Proton pump inhibitor.
D. Oral antihistamine.
E. Short-acting nitrate only.
4. A 61-year-old man presents with central crushing chest pain that started 50 minutes ago and radiates to his left arm. He is pale and sweating. An ECG shows ST-segment elevation in the inferior leads.
Which ONE of the following is the most appropriate immediate management priority?
A. Arrange routine outpatient cardiology review.
B. Start long-term amlodipine.
C. Treat as stable angina.
D. Assess immediately for coronary reperfusion therapy.
E. Supply glyceryl trinitrate and discharge.
5. A 72-year-old woman is taking warfarin for a mechanical heart valve. She is prescribed trimethoprim for a urinary tract infection. Her most recent INR was stable.
Which ONE of the following is the most appropriate concern?
A. Trimethoprim reduces warfarin absorption completely.
B. Trimethoprim may increase the anticoagulant effect of warfarin and bleeding risk.
C. Warfarin prevents trimethoprim from treating infection.
D. INR monitoring can be stopped during antibiotic treatment.
E. The combination routinely causes severe hypotension.
6. A 67-year-old man with stable angina uses glyceryl trinitrate spray before walking uphill. He asks what to do if chest pain occurs and does not improve after the first dose.
Which ONE of the following is the most appropriate advice?
A. Continue walking to improve circulation.
B. Take ibuprofen and wait overnight.
C. Use repeated doses without limit.
D. Skip his next regular anti-anginal medicine.
E. Stop activity, use GTN as directed, and seek emergency help if pain persists.
7. A 70-year-old woman with hypertension is taking ramipril and amlodipine at maximally tolerated doses. Her clinic blood pressure remains 158/92 mmHg. Her renal function is stable and potassium is 4.1 mmol/L.
Which ONE of the following is the most appropriate next antihypertensive option?
A. Indapamide.
B. Verapamil.
C. Digoxin.
D. Aspirin.
E. Furosemide for hypertension only.
8. A 64-year-old man starts ramipril for hypertension. Two weeks later, his serum creatinine has risen from 82 micromol/L to 112 micromol/L and potassium is 5.1 mmol/L. He feels well.
Which ONE of the following is the most appropriate initial interpretation?
A. ACE inhibitors never affect renal function.
B. The result always indicates acute kidney injury requiring dialysis.
C. Potassium monitoring is unnecessary.
D. Creatinine and potassium should be reviewed because ACE inhibitors can affect renal function and potassium.
E. Ramipril should be doubled immediately.
9. A 58-year-old woman taking amlodipine 10 mg daily reports troublesome bilateral ankle swelling. Her blood pressure is controlled and there are no symptoms of heart failure.
Which ONE of the following is the most likely explanation?
A. Severe hypokalaemia.
B. Peripheral oedema caused by amlodipine.
C. Digoxin toxicity.
D. ACE inhibitor-induced cough.
E. Warfarin overdose.
10. A 76-year-old man with atrial fibrillation has a CHA₂DS₂-VASc score of 4. He has no contraindication to anticoagulation but is worried because he occasionally feels unsteady.
Which ONE of the following is the most appropriate advice?
A. Aspirin is preferred to anticoagulation.
B. No treatment is needed if he has no palpitations.
C. Anticoagulation should be considered to reduce stroke risk, while also addressing falls risk.
D. Anticoagulation is only used in patients under 65 years.
E. Warfarin must always be used instead of a DOAC.
11. A 59-year-old man had a myocardial infarction six weeks ago. He is taking aspirin, ticagrelor, atorvastatin, ramipril and bisoprolol. He asks why he needs to continue the statin because his cholesterol is now lower.
Which ONE of the following is the most appropriate explanation?
A. Statins are used only until cholesterol becomes normal.
B. Statins prevent all future chest pain.
C. Statins replace the need for antiplatelet therapy.
D. Statins reduce long-term cardiovascular risk after myocardial infarction.
E. Statins are only prescribed for hypertension.
12. A 74-year-old woman with heart failure takes furosemide 40 mg each morning. She reports dizziness on standing and has had one fall. Her blood pressure is 104/62 mmHg and she has no ankle swelling or breathlessness.
Which ONE of the following is the most appropriate pharmacist contribution?
A. Suggest doubling the furosemide dose.
B. Review for possible over-diuresis and postural hypotension.
C. Advise taking furosemide at bedtime.
D. Add ibuprofen for dizziness.
E. Stop all heart failure medicines permanently.
13. A 63-year-old man with atrial fibrillation is prescribed digoxin for rate control. He later develops nausea, blurred vision and confusion. His renal function has declined since the medicine was started.
Which ONE of the following is the most appropriate concern?
A. Digoxin toxicity.
B. Serotonin syndrome.
C. Statin-induced myopathy.
D. ACE inhibitor cough.
E. Acute gout.
14. A 55-year-old man taking atorvastatin 80 mg daily reports new severe muscle pain and weakness. He has recently completed a course of clarithromycin.
Which ONE of the following is the most appropriate action?
A. Reassure him that severe muscle symptoms are unrelated to statins.
B. Advise him to double the atorvastatin dose.
C. Recommend urgent assessment, including consideration of creatine kinase testing.
D. Add simvastatin.
E. Ignore the clarithromycin history.
15. A 78-year-old woman has resistant hypertension despite ramipril, amlodipine and indapamide at tolerated doses. Her potassium is 4.3 mmol/L and renal function is acceptable.
Which ONE of the following could be considered as a further add-on treatment with monitoring?
A. Aspirin.
B. Salbutamol.
C. Lansoprazole.
D. Ferrous sulfate.
E. Spironolactone.
16. A 69-year-old man with atrial fibrillation takes rivaroxaban once daily. He admits he often misses doses because he feels well and does not notice any symptoms.
Which ONE of the following is the most appropriate counselling point?
A. Rivaroxaban only needs to be taken when palpitations occur.
B. Missing doses is safe because rivaroxaban remains active for several weeks.
C. Aspirin can be used instead on missed days.
D. Regular dosing is important because anticoagulation reduces stroke risk even when atrial fibrillation is asymptomatic.
E. INR testing will show whether he missed a dose.
17. A 66-year-old woman with chronic heart failure reports gaining 3 kg over five days, worsening ankle swelling and breathlessness when lying flat. She is taking her medicines as prescribed.
Which ONE of the following is the most appropriate action?
A. Reassure her that this is expected in stable heart failure.
B. Advise increased salt intake.
C. Arrange urgent clinical review for possible decompensated heart failure.
D. Stop all heart failure medicines.
E. Recommend an antihistamine.
18. A 45-year-old man with hypertension is prescribed ramipril. He develops swelling of his lips and tongue shortly after taking a dose.
Which ONE of the following is the most appropriate advice?
A. Take an antihistamine and continue ramipril.
B. Reduce the ramipril dose by half.
C. Continue treatment and mention it at the next routine review.
D. Switch himself to another ACE inhibitor.
E. Stop ramipril and seek emergency medical attention.
19. A 72-year-old man taking warfarin has an INR of 7.2. He reports passing black stools and feeling light-headed.
Which ONE of the following is the most appropriate management?
A. Continue warfarin unchanged.
B. Treat as possible significant bleeding and arrange urgent medical assessment.
C. Advise eating more green vegetables only.
D. Double the next warfarin dose.
E. Switch to aspirin without review.
20. A 62-year-old woman with hypertension is taking ramipril. She develops a persistent dry cough that has become troublesome. Her blood pressure is controlled and renal function is stable.
Which ONE of the following is the most appropriate management option?
A. Switch to an angiotensin II receptor blocker if clinically appropriate.
B. Add codeine long term and continue ramipril indefinitely.
C. Stop all antihypertensives.
D. Increase ramipril.
E. Replace ramipril with aspirin.
21. A 67-year-old man with stable angina is prescribed bisoprolol. His resting heart rate is 48 bpm and he reports dizziness. He also uses GTN spray occasionally.
Which ONE of the following is the most appropriate action?
A. Increase the bisoprolol dose.
B. Add verapamil without review.
C. Review beta-blocker tolerability because bradycardia may be contributing to symptoms.
D. Stop GTN permanently.
E. Add another rate-limiting medicine.
22. A 70-year-old woman with hypertension is prescribed indapamide. Two weeks later, she reports weakness and muscle cramps. Her sodium is 130 mmol/L and potassium is 3.2 mmol/L.
Which ONE of the following is the most likely explanation?
A. Indapamide-related electrolyte disturbance.
B. Serotonin syndrome.
C. Statin-induced hepatitis.
D. Warfarin overdose.
E. Acute coronary syndrome.
23. A 58-year-old man with atrial fibrillation has a CHA₂DS₂-VASc score of 0. He has no other stroke risk factors and no valvular disease.
Which ONE of the following is the most appropriate antithrombotic approach?
A. Aspirin lifelong.
B. Warfarin with target INR 3.5.
C. Dual antiplatelet therapy.
D. No anticoagulation at present, with reassessment if risk factors change.
E. Enoxaparin lifelong.
24. A 64-year-old woman is prescribed ticagrelor following acute coronary syndrome. She asks what adverse effects she should report urgently.
Which ONE of the following is the most appropriate counselling point?
A. Stop ticagrelor if minor bruising occurs.
B. Report significant or prolonged bleeding.
C. Take ticagrelor only when chest pain occurs.
D. Expect black stools and ignore them.
E. Avoid all aspirin even if prescribed.
25. A 76-year-old man with heart failure is started on spironolactone in addition to ramipril. His baseline potassium is 4.8 mmol/L.
Which ONE of the following is the most important monitoring requirement?
A. Serum amylase.
B. Thyroid function only.
C. Blood glucose every hour.
D. INR.
E. Serum potassium and renal function.
26. A 69-year-old woman presents with palpitations. Her ECG shows a regular narrow-complex tachycardia at 180 bpm. She is alert, her blood pressure is stable and vagal manoeuvres have failed.
Which ONE of the following is the most appropriate next pharmacological treatment?
A. Adenosine.
B. Atorvastatin.
C. Warfarin.
D. Furosemide.
E. Ramipril.
27. A 60-year-old man taking atorvastatin is prescribed erythromycin. He asks whether there is any issue with taking them together.
Which ONE of the following is the most appropriate advice?
A. Erythromycin improves statin safety.
B. Take both medicines with grapefruit juice.
C. Double atorvastatin during the antibiotic course.
D. There are no relevant interactions with any statin.
E. The combination may increase statin exposure and myopathy risk, so the prescriber should review treatment.
28. A 74-year-old woman taking apixaban for atrial fibrillation asks whether she can take ibuprofen regularly for osteoarthritis pain.
Which ONE of the following is the most appropriate advice?
A. Regular ibuprofen is preferred because apixaban protects the stomach.
B. Ibuprofen has no effect on bleeding risk.
C. Regular NSAID use may increase bleeding risk and should be reviewed.
D. Stop apixaban whenever ibuprofen is taken.
E. Add aspirin to reduce bleeding.
29. A 66-year-old man with hypertension has home blood pressure readings that vary widely. He usually measures immediately after walking upstairs and while talking.
Which ONE of the following advice is most appropriate to improve measurement accuracy?
A. Measure after exercise to assess peak blood pressure.
B. Take one reading only when symptomatic.
C. Cross legs during the measurement.
D. Rest quietly before measuring and use a consistent seated technique.
E. Use a wrist cuff over clothing.
30. A 72-year-old man with chronic heart failure has increasing breathlessness. His NT-proBNP is markedly elevated and an echocardiogram is requested.
Which ONE of the following is the primary purpose of echocardiography?
A. Measure cholesterol.
B. Assess cardiac structure, valves and ventricular function.
C. Diagnose diabetes.
D. Confirm urinary infection.
E. Measure INR.
31. A 69-year-old woman with hypertension and type 2 diabetes is taking ramipril. Her urine albumin ratio is elevated and renal function is stable.
Which ONE of the following is the most appropriate reason for using ramipril in this patient?
A. It reduces heart rate.
B. It has renal and cardiovascular protective effects in albuminuric disease.
C. It directly lowers blood glucose.
D. It prevents all urinary tract infections.
E. It replaces diabetes monitoring.
32. A 58-year-old man with stable angina remains symptomatic despite bisoprolol. His heart rate is 52 bpm and blood pressure is 128/76 mmHg.
Which ONE of the following would be most appropriate to consider as an add-on anti-anginal treatment?
A. Verapamil.
B. Ivabradine.
C. Digoxin.
D. Warfarin.
E. Amlodipine.
33. A 77-year-old woman with atrial fibrillation is started on bisoprolol for rate control. One week later, she reports dizziness and fatigue. Her pulse is 42 bpm.
Which ONE of the following is the most appropriate action?
A. Increase bisoprolol.
B. Add diltiazem.
C. Review urgently for symptomatic bradycardia.
D. Reassure and continue without review.
E. Add digoxin immediately.
34. A 63-year-old man taking warfarin has an INR of 1.4. He admits missing several doses. He has a mechanical mitral valve.
Which ONE of the following is the most appropriate pharmacist action?
A. Tell him low INR is safer.
B. Stop warfarin permanently.
C. Switch to aspirin.
D. Escalate for urgent anticoagulation review due to high thrombotic risk.
E. Ignore until next routine appointment.
35. A 65-year-old woman with heart failure with reduced ejection fraction is started on dapagliflozin. She does not have diabetes and asks why it has been prescribed.
Which ONE of the following is the best explanation?
A. It is being used because SGLT2 inhibitors improve outcomes in heart failure, not only because of glucose lowering.
B. It is prescribed only to treat high blood sugar.
C. It replaces all other heart failure medicines.
D. It is a rescue medicine for acute breathlessness.
E. It is only used for hypertension.
36. A 70-year-old man presents with tearing chest pain radiating to his back. He is pale, hypotensive and has unequal arm blood pressures.
Which ONE of the following is the most likely diagnosis?
A. Stable angina.
B. Gastro-oesophageal reflux.
C. Aortic dissection.
D. Uncomplicated hypertension.
E. Costochondritis.
37. A 72-year-old woman with atrial fibrillation is taking warfarin. She asks why she cannot simply switch to apixaban like her neighbour. Her records show she has a mechanical heart valve.
Which ONE of the following is the most appropriate explanation?
A. DOACs are preferred in mechanical valves.
B. Anticoagulation is unnecessary in mechanical valves.
C. Aspirin alone is enough.
D. Mechanical valves require no monitoring.
E. Warfarin remains the appropriate anticoagulant for mechanical heart valves.
38. A 59-year-old man with hypertension is taking doxazosin. He reports dizziness and near-fainting when standing, especially after the first few doses.
Which ONE of the following adverse effects is most likely?
A. Hypoglycaemia.
B. Postural hypotension.
C. Bronchospasm.
D. Hyperthyroidism.
E. Severe hypocalcaemia.
39. A 56-year-old man presents with chest tightness on exertion that resolves with rest. He has not been diagnosed with angina before.
Which ONE of the following is the most appropriate initial action?
A. Treat as suspected angina and refer for clinical assessment.
B. Supply antibiotics.
C. Reassure because exertional chest pain is normal.
D. Start long-term morphine.
E. Diagnose indigestion without assessment.
40. A 68-year-old woman with heart failure takes ramipril, bisoprolol and spironolactone. She is prescribed co-trimoxazole for a urinary tract infection.
Which ONE of the following is the most appropriate concern?
A. Co-trimoxazole improves potassium safety.
B. The combination prevents renal impairment.
C. Spironolactone protects against all antibiotic interactions.
D. Co-trimoxazole may increase the risk of hyperkalaemia, especially with ACE inhibitors and spironolactone.
E. No monitoring is required.
41. A 74-year-old man with heart failure has worsening renal function after his furosemide dose was increased. He has no peripheral oedema, no basal crackles and feels dizzy when standing.
Which ONE of the following is the most appropriate interpretation?
A. Consider volume depletion or over-diuresis and review diuretic therapy.
B. Increase furosemide further.
C. Add ibuprofen.
D. Stop all heart failure medicines permanently.
E. Ignore the renal function change.
42. A 60-year-old man with hypertension and asthma is prescribed a beta-blocker for angina. He reports increased wheeze and shortness of breath shortly after starting treatment.
Which ONE of the following is the most appropriate pharmacist action?
A. Reassure him that beta-blockers cannot affect asthma.
B. Advise him to double the dose.
C. Stop his inhalers.
D. Recommend clinical review because beta-blockers may worsen bronchospasm.
E. Add an NSAID.
43. A 69-year-old woman with atrial fibrillation is admitted with acute kidney injury. She normally takes dabigatran.
Which ONE of the following is the most appropriate consideration?
A. Dabigatran is unaffected by renal function.
B. Continue unchanged without review.
C. Add aspirin to reduce bleeding.
D. Switch to ibuprofen.
E. Renal impairment may increase dabigatran exposure and bleeding risk.
44. A 66-year-old man taking aspirin and ticagrelor after acute coronary syndrome asks why he needs two antiplatelet medicines.
Which ONE of the following is the most appropriate explanation?
A. Ticagrelor treats hypertension.
B. Aspirin and ticagrelor lower blood glucose.
C. Dual antiplatelet therapy reduces the risk of further thrombotic cardiovascular events after acute coronary syndrome.
D. Dual therapy prevents all bleeding.
E. Ticagrelor replaces the need for statins.
45. A 71-year-old woman taking digoxin for atrial fibrillation is prescribed verapamil. She later develops nausea, dizziness and visual disturbance.
Which ONE of the following is the most appropriate concern?
A. Verapamil prevents digoxin absorption completely.
B. Verapamil may increase digoxin levels and toxicity risk.
C. Digoxin prevents verapamil from working.
D. The combination has no cardiac effects.
E. This combination always causes hypokalaemia only.
46. A 57-year-old man with hypertension wants to reduce his cardiovascular risk. He smokes 20 cigarettes daily and has a sedentary lifestyle.
Which ONE of the following advice is likely to provide major cardiovascular benefit?
A. Stop smoking and increase physical activity.
B. Increase salt intake.
C. Avoid all fruit.
D. Take multivitamins instead of prescribed medicines.
E. Drink more sugary drinks.
47. A 62-year-old man with angina is prescribed GTN spray. He also takes sildenafil for erectile dysfunction.
Which ONE of the following counselling point is most important?
A. GTN and sildenafil may be used together safely.
B. Sildenafil prevents GTN headache.
C. GTN should be swallowed.
D. Use extra GTN after sildenafil.
E. Nitrates and sildenafil can cause severe hypotension and should not be used together.
48. A 79-year-old woman with atrial fibrillation has a HAS-BLED score calculated during anticoagulation review.
Which ONE of the following best describes the purpose of this score?
A. To diagnose atrial fibrillation.
B. To estimate bleeding risk and identify modifiable risk factors.
C. To calculate renal function.
D. To decide whether she has heart failure.
E. To measure cholesterol.
49. A 75-year-old man is prescribed rivaroxaban for atrial fibrillation. He asks whether he should stop it before a dental extraction tomorrow.
Which ONE of the following is the most appropriate advice?
A. Stop rivaroxaban permanently.
B. Double the dose today.
C. Replace it with aspirin.
D. Follow the dentist or prescriber’s peri-procedural anticoagulation advice rather than stopping independently.
E. Take ibuprofen before extraction.
50. A 64-year-old woman with hypertension is prescribed ramipril. She is also taking over-the-counter potassium supplements because she believes they are “good for the heart”.
Which ONE of the following is the most appropriate advice?
A. Potassium supplements are always required with ramipril.
B. Ramipril causes severe potassium loss in all patients.
C. Potassium supplements may increase hyperkalaemia risk and should be reviewed.
D. Potassium supplements prevent ACE inhibitor cough.
E. Double the ramipril dose to balance potassium.
Cardiovascular Questions
Answers and Rationale
1. C
For an adult under 55 years who is not of Black African or African-Caribbean family origin and has no contraindications, an ACE inhibitor such as ramipril is an appropriate first-line antihypertensive option.
2. E
DOAC dosing should be reviewed when renal function, age or body weight changes. Apixaban does not require routine INR monitoring, but renal function and patient-specific dose criteria remain important.
3. A
A mineralocorticoid receptor antagonist, such as spironolactone or eplerenone, is part of disease-modifying therapy in suitable patients with heart failure with reduced ejection fraction. Potassium and renal function require monitoring.
4. D
ST-segment elevation myocardial infarction requires immediate assessment for reperfusion therapy, usually primary PCI where available. Delaying treatment for routine review would risk further myocardial damage.
5. B
Trimethoprim can potentiate warfarin and increase bleeding risk. The patient may need closer INR monitoring, an alternative antibiotic or warfarin dose adjustment depending on the clinical situation.
6. E
Persistent angina symptoms despite GTN may indicate acute coronary syndrome. The patient should stop activity, use GTN as directed and seek emergency help if symptoms do not resolve.
7. A
If blood pressure remains uncontrolled on an ACE inhibitor or ARB plus a calcium-channel blocker, adding a thiazide-like diuretic such as indapamide is an appropriate next step.
8. D
ACE inhibitors can cause a rise in creatinine and potassium. The degree of change, clinical status and repeat monitoring help determine whether treatment can continue or requires adjustment.
9. B
Peripheral oedema is a common adverse effect of dihydropyridine calcium-channel blockers such as amlodipine. It can occur even when blood pressure is well controlled.
10. C
A high CHA₂DS₂-VASc score indicates increased stroke risk in atrial fibrillation. Anticoagulation should be considered while also identifying and reducing modifiable falls and bleeding risks.
11. D
High-intensity statin treatment after myocardial infarction is used for secondary prevention. A lower cholesterol result suggests treatment is working, not that it should automatically be stopped.
12. B
Dizziness on standing, low blood pressure and absence of congestion may suggest over-diuresis or postural hypotension. A medicines review is appropriate rather than automatically increasing the diuretic.
13. A
Digoxin toxicity is more likely when renal function declines because digoxin is renally cleared. Nausea, visual disturbance, confusion and arrhythmias are important warning features.
14. C
Severe muscle pain or weakness in a patient taking high-dose statin therapy, especially after an interacting medicine such as clarithromycin, requires urgent assessment and consideration of creatine kinase testing.
15. E
Spironolactone may be considered in resistant hypertension when potassium and renal function are suitable. Ongoing monitoring is essential because of the risk of hyperkalaemia and renal impairment.
16. D
Atrial fibrillation may be asymptomatic, but the risk of thromboembolic stroke remains. Rivaroxaban must be taken regularly as prescribed to maintain anticoagulant protection.
17. C
Rapid weight gain, worsening oedema and orthopnoea suggest fluid retention and possible decompensated heart failure. Prompt clinical review is needed to assess and adjust treatment.
18. E
Lip and tongue swelling after ramipril suggests ACE inhibitor-associated angioedema, which can threaten the airway. The medicine should be stopped and emergency medical attention sought.
19. B
A very high INR with black stools and light-headedness suggests significant bleeding. This requires urgent assessment and reversal decisions rather than routine dose adjustment alone.
20. A
A persistent dry cough is a recognised adverse effect of ACE inhibitors. Switching to an ARB may be appropriate if the ACE inhibitor is otherwise indicated but not tolerated.
21. C
Beta-blockers can cause bradycardia and dizziness. In a symptomatic patient with a resting heart rate of 48 bpm, treatment tolerability and dose appropriateness should be reviewed.
22. A
Thiazide-like diuretics such as indapamide can cause electrolyte disturbances, including hyponatraemia and hypokalaemia. Symptoms such as cramps, weakness and confusion should prompt review.
23. D
A man with atrial fibrillation and CHA₂DS₂-VASc score of 0 is at low stroke risk, so anticoagulation is not routinely indicated at present. Stroke risk should be reassessed if circumstances change.
24. B
Ticagrelor increases bleeding risk. Patients should be counselled to report significant, prolonged or unusual bleeding, including black stools or blood in urine.
25. E
Spironolactone can cause hyperkalaemia, particularly when combined with ACE inhibitors or ARBs. Potassium and renal function should be monitored after initiation and dose changes.
26. A
For stable regular narrow-complex supraventricular tachycardia that does not respond to vagal manoeuvres, adenosine is an appropriate first-line pharmacological option.
27. E
Macrolide antibiotics such as erythromycin can increase exposure to some statins and raise the risk of myopathy or rhabdomyolysis. Treatment should be reviewed.
28. C
NSAIDs can increase gastrointestinal and overall bleeding risk, particularly when combined with anticoagulants. Regular use should be avoided or reviewed carefully.
29. D
Accurate home blood pressure measurement requires resting beforehand, sitting correctly and using a validated device consistently. Talking or measuring immediately after exertion can falsely elevate readings.
30. B
Echocardiography assesses cardiac structure and function, including ventricular ejection fraction and valvular disease. This helps confirm heart failure type and guide treatment.
31. B
ACE inhibitors such as ramipril are useful in people with diabetes and albuminuria because they reduce blood pressure and provide renal and cardiovascular protection when tolerated.
32. E
Amlodipine can be added for angina without further reducing heart rate. Combining rate-limiting calcium-channel blockers such as verapamil with beta-blockers can increase bradycardia risk.
33. C
A pulse of 42 bpm with dizziness and fatigue suggests symptomatic bradycardia. Bisoprolol dose and ongoing suitability should be reviewed urgently.
34. D
A mechanical mitral valve carries high thrombotic risk. A subtherapeutic INR due to missed doses requires urgent anticoagulation review rather than reassurance or switching to aspirin.
35. A
SGLT2 inhibitors are used in heart failure because they reduce heart failure hospitalisation and improve outcomes. Their benefit is not limited to patients with diabetes.
36. C
Sudden tearing chest pain radiating to the back with hypotension and unequal arm blood pressures is highly suggestive of aortic dissection, requiring emergency assessment.
37. E
DOACs are not used for mechanical heart valves. Warfarin remains the appropriate anticoagulant and requires INR monitoring to maintain safe and effective anticoagulation.
38. B
Alpha-blockers such as doxazosin can cause postural hypotension, especially after initiation or dose increases. This can present as dizziness or near-syncope on standing.
39. A
Exertional chest tightness relieved by rest is suggestive of angina and should be clinically assessed. It should not be dismissed or treated as indigestion without evaluation.
40. D
Co-trimoxazole can increase potassium levels, and the risk is greater in patients taking ACE inhibitors and potassium-sparing diuretics such as spironolactone. Monitoring and antibiotic choice should be reviewed.
41. A
Worsening renal function with dizziness and no signs of congestion may suggest volume depletion or over-diuresis. Diuretic therapy and fluid status should be reviewed.
42. D
Beta-blockers can worsen bronchospasm in susceptible patients, including people with asthma. New wheeze or breathlessness after initiation should prompt clinical review.
43. E
Dabigatran is substantially renally cleared. Acute kidney injury can increase drug exposure and bleeding risk, so anticoagulant therapy should be reviewed.
44. C
Dual antiplatelet therapy after acute coronary syndrome reduces the risk of further thrombotic events. Duration depends on the patient’s bleeding risk, ACS type and specialist plan.
45. B
Verapamil can increase digoxin exposure and also has rate-limiting effects. Symptoms such as nausea, dizziness and visual disturbance should prompt review for possible digoxin toxicity.
46. A
Smoking cessation and increased physical activity significantly reduce cardiovascular risk. Lifestyle interventions should be encouraged alongside medicines where indicated.
47. E
Nitrates and phosphodiesterase type 5 inhibitors such as sildenafil can cause profound hypotension when combined. Patients should be counselled clearly about this interaction.
48. B
HAS-BLED estimates bleeding risk in atrial fibrillation and helps identify modifiable risk factors, such as uncontrolled blood pressure, interacting medicines or excess alcohol intake.
49. D
Patients should not stop anticoagulants independently before procedures. Management depends on bleeding risk, renal function, timing and the procedural plan, so prescriber or dentist advice should be followed.
50. C
ACE inhibitors can increase serum potassium. Additional potassium supplements may increase the risk of hyperkalaemia and should be reviewed unless specifically indicated.
Here are 50 multiple-choice questions designed to mimic the GPHC exam itself. At the bottom of the page you will find answers and rationale for each question.