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

Question 1

(17) 45M + HTN + smoker + BMI of 30; Q wants to know best way to decrease BP in this patient; answer?

Answer 1

weight loss; smoking cessation is wrong answer;

Question 2

(17) HY you are aware that weight loss is more important than smoking cessation to decrease BP. Yes, smoking cessation helps, but weight loss is the most effective lifestyle modification.

Answer 2

Since HTN is biggest risk factor for stroke (in patients without Afib), and the best way to decrease BP is weight loss, this means weight reduction is crucial for decreasing stroke risk.

Question 3

(18) 45M + big paragraph vignette that mentions Hx of prosthetic valve and venous disease; Q asks most important indication for anticoagulation in this patient (in other words, what’s biggest risk factor for a clot)?

Answer 3

prosthetic valve.

Question 4

(18) USMLE wants prosthetic valve as most important indication for using warfarin.

The other two HY indications are post-heparin for DVT and elevated CHADS2 for AF.
“Venous disease” does not refer to DVT; venous disease simply means valvular insufficiency causing brawny edema/pigmentation of lower extremities, or sometimes just varicose veins; venous disease is of course an important risk factor for an eventual DVT. USMLE will not give prosthetic valve and DVT for the same Q (some students proceed to ask annoying what-ifs like that).

Answer 4

.

Question 5

(18) most important indication for using warfarin?

Answer 5

USMLE wants prosthetic valve

Question 6

(18) other important factors for warfarin use? 2

Answer 6

The other two HY indications are post-heparin for DVT and elevated CHADS2 for AF.

Question 7

(19) 53F + cirrhosis + lung cancer + severe abdominal pain requiring surgery + laparotomy shows purple, necrosed bowel; diagnosis + risk factors?

Answer 7

Dx is mesenteric venous thrombosis; risk factors are both the cirrhosis (portal vein entering liver is formed from superior mesenteric vein and splenic vein, so cirrhosis means increased pressure/stasis in any of these veins), as well as hypercoagulable state due to malignancy.

Question 8

(19) You should know that cancer/malignancy is important risk factor for clots/DVT, and even marantic endocarditis for that matter.

Answer 8

.

Question 9

(20) 53M + cirrhosis + blood in stool + no pain; Dx + risk factor?

Answer 9

Internal hemorrhoids (painless; external are painful);

risk factor is increased venous pressure in superior rectal veins from cirrhosis (for external hemorrhoids choose inferior rectal veins); other important risk factor is third trimester of pregnancy.

Question 10

(21) 53M + cirrhosis + vomiting copious blood; Dx + risk factor?

Answer 10

ruptured esophageal varices;
risk factor is increased pressure in left gastric vein due to cirrhosis (esophageal veins feed into left gastric, which feeds into portal).

Mallory-Weiss tears due to alcoholism with retching/vomiting often present with “just a little blood”; classically, varices = lots of blood. This isn’t a 100% rule, but it’s usually the case that varices = lots of blood; MW tear = little blood.

Question 11

(22) 50M + undergoing dental procedure; Q asks about risk for endocarditis and if prophylaxis is indicated?

Answer 11

answer on USMLE is almost always do not give prophylaxis.

Only indications are the presence of prosthetic material in the heart or incompletely/unrepaired cyanotic congenital heart disease. The mere presence of a mitral valve prolapse or small ASD/VSD that never became cyanotic is not an indication for prophylaxis. Hx of prior endocarditis is other obvious indication.

Question 12

(23) 45F + HTN + high LDL and TGAs + low HDL + BMI of 23; Q asks most important modification in this patient?

Answer 12

exercise program;

weight loss program is wrong answer (makes sense, since BMI is normal); smoking not listed as answer (if it were, it would be correct answer); this Q shows up on 2CK FM form.

Question 13

(24) 60M + HTN + LV ejection fraction of 35%; Q asks which drug would improve mortality the most?

Answer 13

Answer = lisinopril; ACEi or ARB is first-line for heart failure, as well as for HTN in patients who have diabetes, pre-diabetes, atherosclerotic disease, proteinuria, and/or elevated creatinine or renin. This is not some arbitrary list; this is exceedingly HY for 2CK.

If patient has HTN but does not bear any of the aforementioned scenarios, first-line for HTN is a dihydropyridine CCB (e.g., nifedipine) or HCTZ. It should also be noted that HTN in diabetes is >130/80, whereas everyone else it’s >140/90.

Question 14

(25) 48M + BP 150/90 on multiple visits + normal BMI + non-diabetic; Q wants to know the best therapy for this patient?

Answer 14

hydrochlorothiazide; answer can also be a dCCB.

Vignette doesn’t mention diabetes, pre-diabetes, atherosclerotic disease, or proteinuria (otherwise answer would be ACEi or ARB); if patient is non-diabetic with HTN and has mere elevation in renin or creatinine, I have not seen the NBME force a specific drug here, but I would choose the ACEi or ARB unless the patient has renal artery stenosis or fibromuscular dysplasia (don’t give ACEi or ARB in the latter patients).

Question 15

(26) 38M + diabetic + no protein in the urine + LDL 95 mg/dL + BP 135/80 + HbA1c of 7%; Q asks what is most likely to decrease morbidity in this patient?

Answer 15

lisinopril

as mentioned before, HTN in diabetes is >130/80; first-line is ACEi or ARB. LDL should be <70-100 mg/dL (but on NBME, if <100 a
statin isn’t indicated); HbA1c should be in the 7s or below.

Question 16

(27) 38M + diabetic + mild proteinuria + LDL 95 mg/dL + BP 120/80 + HbA1c of 7%; Q asks what is most likely to decrease morbidity in this patient?

Answer 16

Lisinopril;

Once again, start an ACEi or ARB in
a diabetic if there is 1) any proteinuria; 2) any elevation in creatinine or renin; or 3) BP >130/80.

Question 17

(27) when start an ACEi or ARB in
a diabetic? 3

Answer 17

if there is 1) any proteinuria; 2) any elevation in creatinine or renin; or 3) BP >130/80.

Question 18

(28) 38M + diabetic + no proteinuria + LDL 110 mg/dL + BP 120/80 + HbA1c of 7%; Q asks what is most likely to decrease morbidity in this patient?

Answer 18

Statin.

LDL should be under 100 mg/dL in diabetics on NBME (the literature says <70-100 depending on the source, but I’ve seen NBME Qs where 95 mg/dL LDL is written in vignette and statin isn’t indicated).

Question 19

(29) 38M + no proteinuria + LDL 95 mg/dL + BP 120/80 + HbA1c of 10%; Q asks what is most likely to decrease morbidity in this patient?

Answer 19

commence metformin; patient clearly has diabetes with an HbA1c >7s.

Question 20

(29) Diagnosis of diabetes is any of the following? 3

Answer 20

HbA1c >6.5%;

two fasting glucose measurements 126 mg/dL or greater;

any one random glucose 200 mg/dL or greater.

Question 21

(29) Patients can have normal glucose levels but high HbA1c and therefore be diabetic.

Answer 21

It’s to my observation on NBMEs that if the Q wants glycemic control (e.g., “commence
metformin”) as the answer, they will give HbA1c as >9%, even though technically any
elevation in HbA1c could warrant its commencement.

Question 22

(29) The USMLE Q will often give HbA1c in the 7s as tolerable in a diabetic, where they will make
the focus of the Q something else, e.g., LDL >100 (answer = statin) or proteinuria (answer =
lisinopril).

Answer 22

.

Question 23

HY (30) 50M + diabetic + high LDL + low HDL + high BMI; Q asks best way to decrease long-term complications in this patient?

Answer 23

answer = “good glycemic control”; generic answer, similar to smoking cessation, but
this is HY.

Question 24

HY (31) 50M + diabetic on metformin and glyburide + HbA1c is 12% + bicarb of 20; Q asks #1 way to improve glycemic control?

Answer 24

“switch from metformin and glyburide to intermediate-acting insulin.”

Question 25

(31) This above Q is on an FM form and is one of the most frequently asked-about Qs I know of. Students lose the forest for the trees, thinking the USMLE gives a fuck about hyper-specific Tx regimens. They don’t. Notice the patient has low bicarb (NR 22-28). So you know right away metformin needs to be discontinued (the Q only gives two answers where metformin is discontinued).

Answer 25

If patient is already on glyburide and HbA1c is very high, the assumption is pancreatic burnout has already occurred (patient needs functioning b-cells for sulfonylureas to work), so increasing dose of glyburide won’t work. The remaining answer is just switching to insulin.

Question 26

(31) Since metformin causes lactic acidosis, it is important you know to stop / don’t commence it if patient has low bicarb or creatinine 1.5 or greater (renal insufficiency can increase risk for lactic acidosis due to metformin);

Answer 26

there is an NBME Q where patient has creatinine of 1.4 mg/dL and HbA1c of 12.5% and answer is commence metformin. Although normal creatinine is 0.7-1.2 mg/dL, I’ve observed across NBME Qs that a max of 1.3-1.4 can be considered “normal” if very old (mid-80s+) or urgently requiring glycemic regulation.

Question 27

(32) 50M + on metformin + received IV contrast + now has creatinine of 1.5 mg/dL; Q wants to know what would have prevented this condition?

Answer 27

Intravenous hydration; Dx is contrast nephropathy; metformin does not cause high creatinine; it is merely the case that if a patient has high creatinine, then we discontinue metformin due to lactic acidosis risk.

Question 28

(33) 50M + heavy smoker + Hx of HTN + BMI of 30; Q wants to know best way to decrease diabetes risk in this patient?

Answer 28

weight loss; smoking cessation is wrong answer. For development of type II diabetes, maintaining a normal BMI is most crucial. The answer can also sometimes be “low calorie diet” for these Qs; “low carbohydrate diet” is wrong answer.

Question 29

(34) 65M + long history of alcoholism and smoking + pulsatile mass in epigastrium; Q wants to know #1 way to have prevented this patient’s condition?

Answer 29

smoking cessation;

Question 30

(34) the demographic that classically gets AAA is: elderly males who are ever-smokers; (guidelines says that both, men and women should be screened) alcohol is not salient risk factor; diabetes is actually slightly protective of AAA due to the stiffening effect of glycosylation on endothelium.

Answer 30

Guidelines vary on screening for AAA, but updated literature says both men and women 65- 75 who have ever-smoked should get a one-off abdominal ultrasound to screen for AAA. Lower thresholds can be used in patients with family history.