PLAB 1 Anticoagulation Questions: 10 Free Practice MCQs

Ten PLAB 1-style anticoagulation questions with the answer and the reasoning behind it. They come from the UK.med bank, which has 85 anticoagulation questions and many more across every topic.

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1. 1 / 10

   A 69-year-old with symptomatic AF is stable and needs long-term rate control. There is no heart failure or contraindication to rate-limiting treatment.

   Which initial monotherapy options are recommended?

   • A. A standard beta-blocker or rate-limiting calcium-channel blocker
   • B. Amiodarone or flecainide as monotherapy for every patient
   • C. Digoxin as first choice for every active patient with AF
   • D. Aspirin or clopidogrel
   Show answer

   Answer: A. A standard beta-blocker or rate-limiting calcium-channel blocker

   Why: NICE NG196 Use a standard beta-blocker or rate-limiting calcium-channel blocker for initial AF rate control. Apply this recommendation after confirming the clinical context, reviewing relevant risks and contraindications, and discussing appropriate options with the person. Reassess the plan when their clinical circumstances change.

   • B. NICE NG196: Use a standard beta-blocker or rate-limiting calcium-channel blocker for initial AF rate control. Amiodarone or flecainide for every patient does not follow this recommendation.
   • C. NICE NG196: Use a standard beta-blocker or rate-limiting calcium-channel blocker for initial AF rate control. Digoxin as first choice for every active patient does not follow this recommendation.
   • D. NICE NG196: Use a standard beta-blocker or rate-limiting calcium-channel blocker for initial AF rate control. Aspirin or clopidogrel does not follow this recommendation.

   Sources: NICE NG196 recommendations 1.7.2 and 1.7.3

2. 2 / 10

   A 67-year-old with suspected PE is being assessed with a laboratory D-dimer test.

   Which testing approach may NICE advise considering?

   • A. An age-adjusted D-dimer threshold
   • B. A fixed threshold of zero
   • C. A D-dimer threshold based only on sex
   • D. Avoid D-dimer testing in everyone over 50
   Show answer

   Answer: A. An age-adjusted D-dimer threshold

   Why: NICE NG158 says to consider an age-adjusted D-dimer threshold for people aged over 50 when using point-of-care or laboratory testing. The guideline does not recommend avoiding D-dimer solely because of age.

   • B. A fixed threshold of zero does not follow this pathway. Consider an age-adjusted D-dimer threshold for people over 50.
   • C. A D-dimer threshold based only on sex does not follow this pathway. Consider an age-adjusted D-dimer threshold for people over 50.
   • D. Avoid D-dimer testing in everyone over 50 does not follow this pathway. Consider an age-adjusted D-dimer threshold for people over 50.

   Sources: NICE NG158 recommendation 1.1.14

3. 3 / 10

   A 62-year-old man has confirmed AF but no hypertension, heart failure, diabetes, vascular disease, previous stroke or other CHA2DS2-VASc risk factor.

   What is the appropriate stroke-prevention approach now?

   • A. Do not offer anticoagulation solely for AF stroke prevention at this risk level
   • B. Offer aspirin as an equivalent alternative
   • C. Offer a DOAC because every person with AF needs one, whatever the score
   • D. Use dual antiplatelet therapy
   Show answer

   Answer: A. Do not offer anticoagulation solely for AF stroke prevention at this risk level

   Why: NICE NG196 Do not offer anticoagulation solely for AF stroke prevention to an adult under 65 with no other risk factors. Apply this recommendation after confirming the clinical context, reviewing relevant risks and contraindications, and discussing appropriate options with the person. Reassess the plan when their clinical circumstances change.

   • B. NICE NG196: Do not offer anticoagulation solely for AF stroke prevention to an adult under 65 with no other risk factors. Offer aspirin as an equivalent alternative does not follow this recommendation.
   • C. NICE NG196: Do not offer anticoagulation solely for AF stroke prevention to an adult under 65 with no other risk factors. Offer a DOAC because every person with AF needs one does not follow this recommendation.
   • D. NICE NG196: Do not offer anticoagulation solely for AF stroke prevention to an adult under 65 with no other risk factors. Use dual antiplatelet therapy does not follow this recommendation.

   Sources: NICE NG196 recommendations 1.6.7 and 1.6.14

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5. 4 / 10

   A 74-year-old woman with atrial fibrillation has a CHA2DS2-VASc score of 3 and no contraindication to anticoagulant treatment.

   What does NICE recommend?

   • A. Offer aspirin alone, as it carries less bleeding risk
   • B. Withhold treatment because female sex alone does not count towards her score
   • C. Wait until she has a stroke
   • D. Offer a direct-acting oral anticoagulant, taking bleeding risk into account
   Show answer

   Answer: D. Offer a direct-acting oral anticoagulant, taking bleeding risk into account

   Why: NICE NG196 recommends offering a direct-acting oral anticoagulant to people with AF and a CHA2DS2-VASc score of 2 or above, taking bleeding risk into account. Discuss benefits, risks and the person's preferences.

   • A. NICE says not to offer aspirin monotherapy solely for stroke prevention in AF.
   • B. Her score is above the threshold for offering anticoagulation; female sex alone is not a reason to withhold it.
   • C. Stroke prevention is offered according to risk before a stroke occurs.

   Sources: NICE NG196

6. 5 / 10

   A 70-year-old with atrial fibrillation and a CHA2DS2-VASc score of 3 is suitable for a direct-acting oral anticoagulant. They ask whether NICE requires one particular DOAC for everyone.

   What should guide selection of an anticoagulant?

   • A. Select warfarin for every patient because DOAC choices are not supported by NICE
   • B. Offer a suitable DOAC option after reviewing contraindications, renal function, preferences and practical factors
   • C. Always select apixaban because NICE requires it as the preferred DOAC in every patient
   • D. Choose solely by acquisition cost without discussing the options, as all DOACs are equivalent
   Show answer

   Answer: B. Offer a suitable DOAC option after reviewing contraindications, renal function, preferences and practical factors

   Why: NICE NG196 recommendation 1.6.3 lists apixaban, dabigatran, edoxaban and rivaroxaban as DOAC options when used in line with their technology appraisals. Recommendation 1.6.2 says to discuss benefits and risks and account for contraindications, including BNF and MHRA advice on renal impairment, doses, reversal and monitoring. No single agent is mandated for every person.

   • A. NICE recommends DOAC options for suitable patients who meet the anticoagulation threshold.
   • C. NICE does not select one DOAC as universally preferred; choice should be individualised.
   • D. NICE recommends discussing risks and benefits, contraindications and the person's preferences when choosing treatment.

   Sources: NICE NG196 recommendations 1.6.2, 1.6.3 and 1.6.9

7. 6 / 10

   A 68-year-old woman has newly diagnosed atrial fibrillation. She has no heart failure, hypertension, diabetes, vascular disease or previous stroke. Renal function is suitable for a direct-acting oral anticoagulant.

   What is the recommended approach to stroke prevention?

   • A. Offer a direct-acting oral anticoagulant after discussing benefits, risks and preferences
   • B. Offer aspirin alone as an equivalent alternative with less bleeding
   • C. Withhold treatment because she has no previous stroke
   • D. Wait until she turns 75 before assessing stroke prevention, as her score is low
   Show answer

   Answer: A. Offer a direct-acting oral anticoagulant after discussing benefits, risks and preferences

   Why: NICE NG196 recommendation 1.6.3 recommends offering anticoagulation with a direct-acting oral anticoagulant to people with atrial fibrillation and a CHA2DS2-VASc score of 2 or above, taking bleeding risk into account. In this patient, age 65 to 74 contributes one point and female sex contributes one. The decision and choice of agent should include an informed discussion of risks, benefits and personal preferences.

   • B. NICE advises against aspirin monotherapy solely for stroke prevention in atrial fibrillation.
   • C. A previous stroke is not required to meet the NICE anticoagulation threshold; her CHA2DS2-VASc score is already 2.
   • D. NICE recommends offering anticoagulation at a score of 2 or above; there is no need to wait for age 75.

   Sources: NICE NG196 recommendations 1.6.1 to 1.6.3

8. 7 / 10

   A 76-year-old with atrial fibrillation has a CHA2DS2-VASc score of 5. After reviewing their records, the team determines that all available DOACs are contraindicated because of a documented clinical factor.

   Which anticoagulation strategy does NICE recommend considering next?

   • A. Aspirin monotherapy for stroke prevention
   • B. No further discussion because DOAC contraindication means no option exists
   • C. Offer a vitamin K antagonist after discussing suitability and monitoring
   • D. Use prophylactic-dose heparin indefinitely
   Show answer

   Answer: C. Offer a vitamin K antagonist after discussing suitability and monitoring

   Why: NICE NG196 recommendation 1.6.5 says to offer a vitamin K antagonist to people with atrial fibrillation when DOACs are contraindicated, not tolerated or not suitable. The choice still requires a discussion of the person's circumstances and the monitoring required for a vitamin K antagonist. Aspirin monotherapy is not an equivalent substitute for anticoagulation.

   • A. NICE advises not offering aspirin alone solely for stroke prevention in atrial fibrillation.
   • B. NICE recommends a vitamin K antagonist when a DOAC is contraindicated, not tolerated or unsuitable.
   • D. NICE NG196 does not recommend indefinite prophylactic heparin as the long-term AF stroke-prevention alternative in this situation.

   Sources: NICE NG196 recommendations 1.6.2, 1.6.5 and 1.6.14

9. 8 / 10

   A 30-year-old pregnant female at 12 weeks gestation presents with acute left leg swelling and calf tenderness, with a proximal deep vein thrombosis confirmed on duplex ultrasound.

   What is the anticoagulant of choice?

   • A. Warfarin
   • B. DOAC (e.g., Rivaroxaban)
   • C. Aspirin
   • D. Low Molecular Weight Heparin (LMWH)
   Show answer

   Answer: D. Low Molecular Weight Heparin (LMWH)

   Why: Low Molecular Weight Heparin (LMWH) is the first-line anticoagulant for treating venous thromboembolism (VTE) in pregnancy according to RCOG/NICE guidelines, as it does not cross the placenta and carries no risk of fetal teratogenicity. Option A (warfarin) is teratogenic causing fetal warfarin syndrome; Option B (DOACs like rivaroxaban) cross the placenta with uncertain fetal toxicity; Option C (aspirin) is inadequate monotherapy for acute DVT.

   • A. Teratogenic, avoided in pregnancy.
   • B. Not licensed/sufficient safety data for pregnancy.
   • C. Ineffective for treating acute DVT.

   Sources: RCOG Guidelines

10. 9 / 10

    A 67-year-old female is diagnosed with new-onset paroxysmal atrial fibrillation. She has a history of well-controlled hypertension and type 2 diabetes. She has no history of stroke, TIA, or vascular disease.

    What is her CHA2DS2-VASc score, and what is the recommended stroke prevention strategy?

    • A. Score of 2; offer antiplatelet therapy with Aspirin 75mg daily
    • B. Score of 4; offer anticoagulation with a Direct Oral Anticoagulant (DOAC)
    • C. Score of 3; offer anticoagulation with Warfarin only
    • D. Score of 1; no anticoagulation required
    Show answer

    Answer: B. Score of 4; offer anticoagulation with a Direct Oral Anticoagulant (DOAC)

    Why: Her CHA2DS2-VASc score is 4: one point each for age 65 to 74, hypertension, diabetes and female sex. NICE NG196 recommends offering a DOAC when the score is 2 or more, after considering bleeding risk and discussing options and preferences. Aspirin is not offered solely for stroke prevention in AF.

    • A. NICE does not recommend aspirin solely for stroke prevention in AF. Assess stroke risk and discuss anticoagulation options.
    • C. NICE recommends a DOAC for eligible people with non-valvular AF, rather than restricting treatment to warfarin.
    • D. Her score is 4 because age 65 to 74, hypertension, diabetes and female sex each contribute one point.

    Sources: NICE NG196 recommendations 1.2.1, 1.2.4 and 1.6.1

11. 10 / 10

    A 58-year-old man with atrial fibrillation has hypertension but no other stroke risk factors. He has no contraindication to anticoagulation and asks whether a blood thinner is indicated.

    How should anticoagulation be approached under NICE guidance?

    • A. Offer aspirin because his score is below 2, as anticoagulation is only for higher scores
    • B. Consider a direct-acting oral anticoagulant after assessing bleeding risk and discussing his preferences
    • C. Do not discuss anticoagulation unless he develops heart failure
    • D. Use a vitamin K antagonist as the only available option for a man with a score of 1
    Show answer

    Answer: B. Consider a direct-acting oral anticoagulant after assessing bleeding risk and discussing his preferences

    Why: NICE NG196 recommendation 1.6.4 says to consider anticoagulation with a DOAC for men with atrial fibrillation and a CHA2DS2-VASc score of 1, taking bleeding risk into account. This is an individual discussion rather than an automatic treatment threshold. Aspirin alone is not an alternative stroke-prevention strategy for atrial fibrillation.

    • A. Aspirin monotherapy should not be offered solely for stroke prevention in atrial fibrillation.
    • C. NICE says to consider a DOAC for men with a score of 1; heart failure is not required for that discussion.
    • D. NICE recommends considering a DOAC when suitable; a vitamin K antagonist is offered when DOACs are unsuitable, contraindicated or not tolerated.

    Sources: NICE NG196 recommendations 1.6.1, 1.6.2, 1.6.4 and 1.6.14

Exam-style questions written by MedHub for practice. They are not official exam questions.