PLAB 1 Atrial fibrillation Questions: 10 Free Practice MCQs

Ten PLAB 1-style atrial fibrillation questions with the answer and the reasoning behind it. They come from the UK.med bank, which has 70 atrial fibrillation questions and many more across every topic.

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1. 1 / 10

   A 67-year-old with persistent atrial fibrillation diagnosed 6 months ago has a ventricular rate of 118 beats per minute and troublesome palpitations. They are haemodynamically stable and have no heart failure or contraindication to rate-limiting treatment.

   Which is an appropriate initial rate-control strategy in this non-acute setting?

   • A. Offer a standard beta-blocker or a rate-limiting calcium-channel blocker, choosing with the person based on symptoms and comorbidities
   • B. Use digoxin as first-line monotherapy for every physically active patient, adding a beta-blocker only if the rate stays high
   • C. Start amiodarone as routine first-line long-term rate control in persistent atrial fibrillation
   • D. Use flecainide for rate control, with a beta-blocker added if the rate stays above 110
   Show answer

   Answer: A. Offer a standard beta-blocker or a rate-limiting calcium-channel blocker, choosing with the person based on symptoms and comorbidities

   Why: NICE NG196 recommendation 1.7.2 recommends either a standard beta-blocker or a rate-limiting calcium-channel blocker such as diltiazem or verapamil for initial rate-control monotherapy, with the choice based on symptoms, heart rate, comorbidities and preferences. Recommendation 1.7.3 directs clinicians to heart-failure guidance for people with concomitant heart failure.

   • B. NICE reserves consideration of digoxin monotherapy for non-paroxysmal AF when the person does little or no exercise, or other rate-limiting options are ruled out.
   • C. NICE recommends a standard beta-blocker or rate-limiting calcium-channel blocker as initial rate-control monotherapy for most people.
   • D. Flecainide is an antiarrhythmic considered for rhythm control in selected people, not routine initial rate-control monotherapy.

   Sources: NICE NG196 recommendations 1.7.2 and 1.7.3

2. 2 / 10

   A 69-year-old with atrial fibrillation has a CHA2DS2-VASc score of 2. They are worried about bruising and ask to be involved in choosing whether and how to take anticoagulation.

   What is the most appropriate consultation approach?

   • A. Explain the benefits and risks using their clinical risk profile and preferences to guide the choice
   • B. Prescribe the cheapest available option without discussing alternatives
   • C. Use the risk score alone and do not discuss bleeding because it may cause anxiety
   • D. Ask the family to decide because anticoagulation choices are too complex for patients
   Show answer

   Answer: A. Explain the benefits and risks using their clinical risk profile and preferences to guide the choice

   Why: NICE NG196 recommendations 1.6.1 and 1.6.2 require discussion of clinical risk profiles, the benefits and risks of available anticoagulants, contraindications and personal preferences. Recommendation 1.4.2 directs clinicians to NICE shared decision-making guidance. A CHA2DS2-VASc score informs the discussion but does not replace a conversation about bleeding, treatment burden or what matters to the person.

   • B. NICE recommends discussing treatment options and following shared decision-making principles.
   • C. NICE specifically advises discussing bleeding risk as well as stroke prevention and taking the person's preferences into account.
   • D. The person should be involved in decisions about their medicines; family involvement depends on their agreement or applicable capacity arrangements.

   Sources: NICE NG196 recommendations 1.4.2 and 1.6.1 to 1.6.3

3. 3 / 10

   A 78-year-old with atrial fibrillation has agreed to start anticoagulation after stroke-risk assessment. There is no murmur, heart failure symptom or separate indication for an echocardiogram.

   Is transthoracic echocardiography routinely needed solely to refine stroke risk now?

   • A. Yes, repeat TTE every 6 months for everyone with AF
   • B. Yes, because anticoagulation cannot be started without a TTE excluding left atrial thrombus
   • C. No, do not perform TTE solely for further stroke-risk stratification after the anticoagulation decision is agreed
   • D. Use TOE instead, because it is less invasive than TTE and more accurate for stroke risk
   Show answer

   Answer: C. No, do not perform TTE solely for further stroke-risk stratification after the anticoagulation decision is agreed

   Why: NICE NG196 recommendation 1.3.2 says not to routinely perform transthoracic echocardiography solely for further stroke-risk stratification in people with atrial fibrillation when the need for anticoagulation has already been agreed on appropriate clinical criteria. TTE remains appropriate for specific management questions, such as suspected structural disease or a rhythm-control strategy involving cardioversion.

   • A. NICE does not recommend routine TTE for this purpose once anticoagulation is agreed on appropriate clinical criteria.
   • B. NICE does not require TTE before anticoagulation when the decision is already agreed on appropriate clinical criteria.
   • D. TOE is not a routine substitute; NICE reserves it for selected structural assessment or TOE-guided cardioversion.

   Sources: NICE NG196 recommendations 1.3.1 and 1.3.2

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5. 4 / 10

   A 72-year-old man presents with mild shortness of breath on exertion. An ECG reveals atrial fibrillation with a ventricular rate of 115 bpm. He has a history of mild COPD but no history of heart failure or structural heart disease.

   What is the recommended first-line pharmacological agent for rate control according to NICE guidelines?

   • A. A beta-blocker (e.g. Bisoprolol)
   • B. Digoxin as monotherapy
   • C. Amiodarone (oral loading)
   • D. Flecainide (pill in the pocket)
   Show answer

   Answer: A. A beta-blocker (e.g. Bisoprolol)

   Why: NICE guideline NG196 states that rate control should be the first-line treatment strategy for atrial fibrillation in most patients, unless they are unstable, have a reversible cause, or have new-onset AF (<48h). First-line monotherapy is a beta-blocker (other than Sotalol) or a rate-limiting calcium channel blocker (Diltiazem or Verapamil; avoided in heart failure). Digoxin is only preferred first-line in sedentary individuals.

   • B. Digoxin is not recommended first-line for rate control in active patients because it only controls heart rate at rest (via vagal tone) and is ineffective during exercise, and is reserved for sedentary patients or heart failure co-prescription.
   • C. Amiodarone is a rhythm control drug (antiarrhythmic) with significant long-term toxicities (thyroid, pulmonary, hepatic) and is not used first-line for simple rate control.
   • D. Flecainide is used for rhythm control (pill-in-the-pocket or maintenance) and is contraindicated in structural or ischaemic heart disease, not for routine rate control.

   Sources: NICE NG196

6. 5 / 10

   A 64-year-old with atrial fibrillation was not anticoagulated because their initial CHA2DS2-VASc score was 0. They have now turned 65 and have no new symptoms.

   What should the clinician do about stroke risk?

   • A. Continue the original decision without reassessment until age 75
   • B. Start aspirin without reviewing other risk factors, as turning 65 adds one point
   • C. Reassess the CHA2DS2-VASc score and discuss anticoagulation if the updated risk warrants it
   • D. Wait for a transient ischaemic attack before reassessing the score
   Show answer

   Answer: C. Reassess the CHA2DS2-VASc score and discuss anticoagulation if the updated risk warrants it

   Why: NICE NG196 recommendation 1.6.15 says to review stroke risk in people with atrial fibrillation who are not taking anticoagulation when they reach age 65 or develop specified risk factors at any age. The risk profile can change over time, so an earlier low-risk decision should not be treated as permanent. Reassess, explain the result and make a shared decision about treatment.

   • A. NICE says to review stroke risk when a person not anticoagulated reaches age 65.
   • B. Aspirin monotherapy is not recommended solely for stroke prevention in atrial fibrillation.
   • D. Risk reassessment is recommended at age 65; waiting for a cerebrovascular event would miss preventive care.

   Sources: NICE NG196 recommendation 1.6.15

7. 6 / 10

   A 71-year-old with persistent atrial fibrillation has a CHA2DS2-VASc score of 3 but is not taking anticoagulation. They ask whether daily aspirin can replace an anticoagulant for stroke prevention.

   What is the best response?

   • A. Aspirin is preferred because atrial fibrillation causes platelet-rich clots
   • B. Aspirin is acceptable if taken with a proton pump inhibitor
   • C. Use aspirin until the CHA2DS2-VASc score reaches 4
   • D. Explain that aspirin alone is not recommended and discuss appropriate anticoagulation
   Show answer

   Answer: D. Explain that aspirin alone is not recommended and discuss appropriate anticoagulation

   Why: NICE NG196 recommendation 1.6.14 says not to offer aspirin monotherapy solely for stroke prevention in atrial fibrillation. With a CHA2DS2-VASc score of 3, recommendation 1.6.3 supports offering anticoagulation with a DOAC after considering bleeding risk and the person's preferences. An antiplatelet may still be needed for a separate clinical indication, but that is a different decision.

   • A. NICE specifically says not to offer aspirin monotherapy solely for stroke prevention in atrial fibrillation.
   • B. A proton pump inhibitor does not make aspirin an appropriate sole stroke-prevention treatment for AF.
   • C. NICE recommends offering a DOAC at a score of 2 or above, and does not endorse aspirin as a substitute solely for this purpose.

   Sources: NICE NG196 recommendations 1.6.3 and 1.6.14

8. 7 / 10

   A 66-year-old with atrial fibrillation is being considered for elective rhythm control that includes cardioversion. Baseline cardiac structure and function will affect long-term management.

   Which cardiac investigation does NICE recommend in this situation?

   • A. No imaging under any circumstances before rhythm control
   • B. Transthoracic echocardiography
   • C. Routine coronary angiography
   • D. A 24-hour ambulatory ECG as the only cardiac structural assessment
   Show answer

   Answer: B. Transthoracic echocardiography

   Why: NICE NG196 recommendation 1.3.1 recommends transthoracic echocardiography when a baseline echocardiogram is important for long-term management, when a rhythm-control strategy including cardioversion is considered, or when suspected structural or functional disease affects management. The investigation should answer a clinical question rather than be ordered routinely for every person with atrial fibrillation.

   • A. NICE supports TTE when rhythm control involving cardioversion is being considered or baseline information is important for long-term management.
   • C. NICE does not recommend routine coronary angiography for every person with AF being considered for cardioversion.
   • D. Ambulatory ECG does not assess cardiac structure or function; NICE recommends TTE for relevant structural assessment.

   Sources: NICE NG196 recommendation 1.3.1

9. 8 / 10

   A 73-year-old with atrial fibrillation has a CHA2DS2-VASc score of 3 and a raised ORBIT bleeding-risk score. They have uncontrolled blood pressure and regular use of an anti-inflammatory medicine.

   How should the raised bleeding-risk score influence the anticoagulation discussion?

   • A. Use it to identify modifiable bleeding risks, discuss the balance of benefit and harm, and plan monitoring
   • B. Treat it as an absolute contraindication to every anticoagulant until the score falls
   • C. Replace anticoagulation with aspirin, which carries a lower bleeding risk
   • D. Ignore the score because stroke prevention takes priority in every patient
   Show answer

   Answer: A. Use it to identify modifiable bleeding risks, discuss the balance of benefit and harm, and plan monitoring

   Why: NICE NG196 recommendations 1.6.1 and 1.6.2 call for clinical risk profiles and personal preferences to guide anticoagulation choices. Bleeding-risk tools should generally prompt clinicians to identify and manage modifiable factors, such as uncontrolled blood pressure or interacting medicines, rather than serve as a sole reason to deny treatment. The decision should balance both risks and be reviewed.

   • B. NICE says to take bleeding risk into account but does not make a raised score an automatic contraindication.
   • C. Aspirin monotherapy is not recommended solely for stroke prevention in atrial fibrillation.
   • D. NICE recommends careful monitoring and shared consideration of bleeding risk, rather than ignoring it.

   Sources: NICE NG196 recommendations 1.2.2 and 1.6.1 to 1.6.3

10. 9 / 10

    A 74-year-old presents with palpitations and an irregularly irregular pulse. The initial assessment has not yet confirmed the rhythm.

    Which investigation should confirm suspected atrial fibrillation?

    • A. A 12-lead ECG
    • B. A pulse oximetry reading
    • C. A chest radiograph
    • D. An echocardiogram alone
    Show answer

    Answer: A. A 12-lead ECG

    Why: NICE NG196 Offer a 12-lead ECG to confirm suspected AF when an irregular pulse is detected. 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: Offer a 12-lead ECG to confirm suspected AF when an irregular pulse is detected. A pulse oximetry reading does not follow this recommendation.
    • C. NICE NG196: Offer a 12-lead ECG to confirm suspected AF when an irregular pulse is detected. A chest radiograph does not follow this recommendation.
    • D. NICE NG196: Offer a 12-lead ECG to confirm suspected AF when an irregular pulse is detected. An echocardiogram alone does not follow this recommendation.

    Sources: NICE NG196 recommendations 1.1.1 and 1.1.2

11. 10 / 10

    An 82-year-old with persistent atrial fibrillation has a CHA2DS2-VASc score of 4 and has fallen twice in the past year. There is no current bleeding or other contraindication to anticoagulation.

    How should age and falls affect the decision about stroke prevention?

    • A. Withhold anticoagulation because age over 80 with recurrent falls is an exclusion
    • B. Use aspirin instead because it prevents stroke without fall-related bleeding
    • C. Withhold treatment until the person has a fall-free year, then reassess the CHA2DS2-VASc score
    • D. Discuss and offer anticoagulation when appropriate, considering their full clinical risk profile and preferences
    Show answer

    Answer: D. Discuss and offer anticoagulation when appropriate, considering their full clinical risk profile and preferences

    Why: NICE NG196 recommendations 1.6.3 and 1.6.8 recommend offering a DOAC at a CHA2DS2-VASc score of 2 or above and explicitly advise not withholding anticoagulation solely because of age or risk of falls. Discuss benefits, bleeding risk, modifiable hazards and the person's preferences. Falls still warrant assessment and risk reduction, but are not by themselves an exclusion.

    • A. NICE specifically advises not withholding anticoagulation solely because of age.
    • B. NICE does not recommend aspirin monotherapy solely for stroke prevention in atrial fibrillation.
    • C. NICE says not to withhold anticoagulation solely because of falls; address individual bleeding risks and preferences.

    Sources: NICE NG196 recommendations 1.6.1, 1.6.3 and 1.6.8

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