Mehl. Risk factors 1 (cardio) 04-22 (2)

Question 1

(1) 45M + BMI of 40 + Hx of hypertension (HTN) + 10-pack-yr Hx of smoking; Q asks what is most likely to be beneficial for this patient?

Answer 1

smoking cessation

Question 2

(1) When in doubt, “smoking cessation” is the most common overall answer on NBME/USMLE for the #1 way to improve general health.

Answer 2

The stem might be a long, rambling vignette where the dude is overweight, smokes, has high blood pressure, etc., and they ask broadly/vaguely what is most likely to improve mortality/morbidity -> answer = smoking cessation.

Question 3

(2) 67F + diabetic + smoker + HTN; Q asks which of the following is biggest risk factor for developing an MI in this patient?

Answer 3

Diabetes

Question 4

(2) Diabetes (I and II), followed by …, followed by …., in that order, are the most acceleratory (i.e., worst) risk factors for atherosclerosis. Patients with diabetes are managed as a cardiovascular disease equivalent.

Answer 4

Diabetes (I and II), followed by smoking, followed by HTN

Question 5

(2) most common risk factor in the population for atherosclerosis?

Answer 5

HTN

Question 6

(2) HTN is most common risk factor in the population for atherosclerosis, but diabetes, followed by smoking, are the two most acceleratory / worst. HTN doesn’t cause plaque development as fast as diabetes or smoking.

Answer 6

.

Question 7

(2) risk factor most acceleratory for atherosclerosis of the carotid arteries?

Answer 7

HTN is only most acceleratory for atherosclerosis of the carotid arteries, which I will discuss in detail below. If not the carotids, we have diabetes -> smoking -> HTN.

Question 8

(2) If Q asks about how to decrease peri- or post-operative MI risk, answer on nbme?

Answer 8

answer will be smoking cessation on NBME. This is presumably because smoking cessation acutely improves blood flow + oxygen utilization at myocardium.

Question 9

(3) 67F + smoker + HTN + high BMI; Q asks biggest risk factor for developing an MI in this patient?

Answer 9

Smoking.

As we said above, the order of importance for atherosclerosis leading to MI is diabetes -> smoking -> HTN. This is asked on one of the NBME exams, where it’s a 1-2-liner Q followed by smoking being correct over HTN.

Question 10

(4) 60F + diabetic + HTN + smoker + about to undergo hip surgery; Q asks for the best way to reduce perioperative MI risk?

Answer 10

smoking cessation

Question 11

(4) number 1 to reduce perioperative MI risk?

Answer 11

As mentioned above, smoking cessation is #1 way to reduce peri- and post-operative MI risk, since acute smoking cessation improves myocardial oxygenation and coronary autoregulation.

Question 12

(5) 65F + 80-pack-year Hx of smoking + CXR shows hyperinflation + loud P2 on auscultation + JVD + ECG shows right-axis deviation + 2-year Hx of type II diabetes; Q asks what is most likely to reduce MI risk in this patient?

Answer 12

smoking cessation

Question 13

(5) Inflated lung fields mean COPD. Loud P2 means pulmonary hypertension (pulmonic valve slams shut due to high distal pressure). JVD means impaired right-heart filling. Right-axis deviation means right ventricular hypertrophy. You need to avoid being intransigently rigid when approaching questions. If the vignette overwhelmingly emphasizes one presentation over another (i.e., obvious cor pulmonale versus mere peripheral mention of recent diabetes), you need to be able to reason that the Q wants a particular answer (i.e., smoking here over diabetes).

Answer 13

.

Question 14

(6) 60F + Hx of MI 5 years ago + diabetic + smoker + HTN; Q asks number-one risk factor for an MI occurring in this patient?

Answer 14

Hx of myocardial infarction.

Not complicated. Akin to psych questions that want you to know biggest risk factor for suicide is Hx of previous suicide attempt.

Question 15

(7) Question gives 40s male with duodenal ulcers caused by H. pylori. Following antibiotic treatment, they ask what lifestyle variable is most likely to promote healing of ulcers?

Answer 15

Smoking cessation.

Reducing alcohol intake can also help, but I’ve seen smoking cessation as answer on NBME, where they don’t have abstinence from alcohol as an answer.

Question 16

(8) Patient has autoimmune disease (i.e., SLE, RA, etc.); question wants to know how to decrease recurrence of flares?

Answer 16

smoking cessation.

Question 17

(9) 4F + recurrent otitis media + parents smoke but only outside; Q asks #1 way to decrease recurrence of otitis media in this patient (answers are all lifestyle/household variables)?

Answer 17

Parental smoking cessation; even though “only outside,” second-hand smoke is important cause of recurrent upper respiratory tract/ear infections and sudden infant death syndrome on USMLE.

Question 18

(10) 11F + rhinoconjunctivitis past month; Q asks what to ask parents about -> answer =?

Answer 18

“recent pets in household”;

if recent allergy-like presentation in a patient with no prior Hx, inquire about pets.

Question 19

(11) 55M + gangrene of the fingers + HTN + drinks alcohol and smokes; Q wants to know #1 way to improve this patient’s condition?

Answer 19

smoking cessation;

diagnosis is Buerger disease (thromboangiitis obliterans), which is idiopathic digital gangrene, generally in middle-age men who are heavy smokers.

Question 20

very HY !!!!!!!!!!!!!!!!!!! (12) 66M + experiences stroke + has Hx of hypertension and smoking; Q asks #1 way to decrease risk of recurrent stroke?

Answer 20

answer = lisinopril; smoking cessation is wrong answer.

Question 21

!!!!!!!! (12) what has higher risk for stroke: HTN or smoking?

Answer 21

You need to know hypertension eclipses smoking as the bigger risk factor for stroke.
The order of risk factors for stroke on NBME/USMLE is: atrial fibrillation (AF) –> HTN –> smoking.

This vignette is exceedingly HY, particularly for 2CK.

Question 22

!!!!!!!! (12) The order of risk factors for stroke on NBME/USMLE is: ?3

Answer 22

atrial fibrillation (AF) –> HTN –> smoking.

Question 23

!!!!!!!! (12). The answer on USMLE for reducing stroke risk in a hypertensive patient without AF will often just be “lisinopril,” rather than “management of hypertension.” Lisinopril, to my observation, is a favorite drug on NBME forms. Patients who have stroke risk need to be on an ACEi or ARB.

Answer 23

High blood pressure leads to a strong systolic impulse pounding the carotidsàendothelial damageàatheromata development (carotid stenosis due to atherosclerosis)àplaque launches off to the brain/eye causing stroke, TIA, and retinal artery occlusion.

Question 24

!!!!!!!! (12) Should be noted that of course smoking cessation should be implemented in patients at risk for stroke, but HTN eclipses smoking for risk factor importance.

Answer 24

Patients who have diabetes and/or are smokers who don’t have HTN will absolutely develop diffuse atherosclerosis, but vessels such as the abdominal aorta, coronaries, and popliteals classically develop plaques first.

It is specifically hypertension that affects the carotids.

Question 25

!!!!!!!! (12) It is specifically hypertension that affects the carotids.

Answer 25

.

Question 26

(13) 66M + experiences retinal artery occlusion + has Hx of hypertension and smoking; last line of the Q says “carotid duplex ultrasonography shows 90% occlusion”; Q asks what’s the best way to decrease recurrence of stroke?

Answer 26

carotid endarterectomy; lisinopril is wrong answer (offline NBME 8 for 2CK). Student says, “Wait, didn’t you just say lisinopril is the answer they want for reducing risk of stroke -> You’re right. But if they tell you specifically that the patient has high degree of occlusion on carotid ultrasound, then answer = carotid endarterectomy over lisinopril.

Question 27

(13) When to do carotid endarterectomy?2

Answer 27

Symptomatic carotid stenosis >70% (i.e., Hx of stroke, TIA, or retinal artery occlusion) or asymptomatic carotid stenosis >80% (i.e., no Hx of stroke, TIA, or retinal artery occlusion; mere presence of a carotid bruit does not refer to symptoms). Students get pedantic about the above %s, but in reality, the NBME won’t make the degree of occlusion borderline. They’ll either say something like 90% or 30%.

Question 28

(13) If patient is under endarterectomy % thresholds, the treatment = the triad of drugs?

Answer 28

1) antiplatelet therapy (usually aspirin alone is answer on NBME, but can be combo of aspirin + dipyridamole, OR clopidogrel alone); 2) statin; 3) ACEi or ARB.

Question 29

(14) 65M + S4 heart sound + paradoxical splitting of S2 + left bundle branch block + lateralized apical impulse + ECG shows left-axis deviation + BP is 160/95 + smoker past 20 years; Q asks what is most likely to have prevented this patient’s findings?answer = ?

Answer 29

management of hypertension”; smoking cessation is wrong answer.

Question 30

(14) Before you freak out, I’ll unpack the above findings: S4 heart sounds on USMLE = stiff left ventricle from high afterload (usually systemic hypertension, but can be aortic stenosis). When you see S4, you should be thinking “ok that’s diastolic dysfunction and a stiff LV from some form of afterload, most likely AS or HTN.”

Answer 30

Paradoxical splitting of S2 (when A2 occurs after P2), LBBB, and left-axis deviation on ECG all = left ventricular hypertrophy. That’s it. You don’t need to worry about mechanisms or anything more. So the above vignette, if we summarize it, basically screams hypertensive heart disease. The patient has LVH due to HTN. The smoking is bad, yes, but the focus of the vignette is clearly the HTN. This is a 2CK-level Q. For those of you studying for Step 1 confused about cardio stuff, my HY Cardio PDF discusses these things in more detail.

Question 31

(15) 79M + irregularly irregular rhythm on ECG + history of HTN; Q asks most important risk factor for stroke in this patient?

Answer 31

answer = atrial fibrillation, not hypertension. Once again, the order for stroke risk on NBME/USMLE is: atrial fibrillation -> hypertension -> smoking. If they mention any of these in the same patient, AF eclipses HTN, which eclipses smoking.

Question 32

(15) AF can cause left atrial mural thrombi that launch off to the brain/eye; HTN causes carotid atheromatous plaques that launch off.

Answer 32

AF is most common in patients over 75, or occasionally in select patient groups such as those with hyperthyroidism.

Question 33

(16) 79M + atrial fibrillation + HTN; Q wants to know best way to decrease stroke risk in this patient?

Answer 33

Answer = warfarin; aspirin is wrong answer;

Question 34

(16) USMLE wants you to know CHADS2 score (there are variations, but this simple one suffices). Each component is one point -> Congestive heart failure; Hypertension, Age >75, Diabetes. Stroke or TIA is 2 points. As cardio kortose esu su chads-vasc padarius, lengiau taip suskaiciuoti, nes dasideda lytis, mazesnis amzius, kraujagysles

Answer 34

If patient has Afib and 0 or 1 points from CHADS2 score, give aspirin; if 2+ points, give warfarin. NBME doesn’t really assess the non-warfarin NOACs. The exam-writers seem to be pretty old-school and just stick with warfarin, likely because it avoids ambiguity for NOAC use cases.