Chapter 13 Flashcards
A 50-year-old woman presents to your clinic today for routine follow-up on her hypertension,
cholesterol, and type 2 diabetes mellitus. Her mother is alive, but her father passed away at age 55 from a myocardial infarction. She tries to follow a low sugar and low sodium diet. The patient smokes one pack of cigarettes per day but is otherwise healthy. Her lipid panel today is total cholesterol 220 mg/dL (5.69 mmol/L), HDL cholesterol 45 mg/dL (1.16 mmol/L), and
triglycerides 160 mg/dL (1.81 mmol/L).
What is this patient’s primary target for intervention?
A. Triglycerides and non-HDL cholesterol
B. Triglycerides and HDL cholesterol
C. HDL cholesterol and LDL cholesterol
D. Non-HDL cholesterol and LDL cholesterol
Option D: Correct. Both non-HDL cholesterol and LDL cholesterol are considered primary
cholesterol targets by the NLA, AACE/ACE, and ACC guidelines and should be targeted in this
patient.
A 50-year-old woman presents to your clinic today for routine follow-up on her hypertension,
cholesterol, and type 2 diabetes mellitus. Her mother is alive, but her father passed away at age 55 from a myocardial infarction. She tries to follow a low sugar and low sodium diet. The patient smokes one pack of cigarettes per day but is otherwise healthy. Her lipid panel today is total cholesterol 220 mg/dL (5.69 mmol/L), HDL cholesterol 45 mg/dL (1.16 mmol/L), and
triglycerides 160 mg/dL (1.81 mmol/L).
1. What is this patient’s non-HDL cholesterol and LDL cholesterol?
A. 150 mg/dL (3.88 mmol/L) and 134 mg/dL (3.47 mmol/L)
B. 175 mg/dL (4.51 mmol/L) and 143 mg/dL (3.70 mmol/L)
C. 190 mg/dL (4.91 mmol/L) and 157 mg/dL (4.06 mmol/L)
D. 200 mg/dL (5.17 mmol/L) and 170 mg/dL (4.40 mmol/L)
Option B: Correct. The calculation for non-HDL cholesterol is total cholesterol – HDL
cholesterol (220 – 45 = 175) or (5.67 – 1.16 = 4.51). The calculation for LDL cholesterol is total
cholesterol – (HDL cholesterol + triglycerides/5) (220 – [45 + 160/5] = 143) or total cholesterol
– (HDL cholesterol + triglycerides/2.2) (5.67 – [1.16 + 1.81/2.2] = 3.70).
A 50-year-old woman presents to your clinic today for routine follow-up on her hypertension,
cholesterol, and type 2 diabetes mellitus. Her mother is alive, but her father passed away at age 55 from a myocardial infarction. She tries to follow a low sugar and low sodium diet. The patient smokes one pack of cigarettes per day but is otherwise healthy. Her lipid panel today is total cholesterol 220 mg/dL (5.69 mmol/L), HDL cholesterol 45 mg/dL (1.16 mmol/L), and
triglycerides 160 mg/dL (1.81 mmol/L).
According to the 2018 AHA/ACC cholesterol guideline, which medication would be the most
appropriate to start in this patient?
A. Rosuvastatin 10 mg daily
B. Bempedoic acid 180 mg daily
C. Ezetimibe 10 mg daily
D. Simvastatin 10 mg daily
Option A: Correct. The patient is indicated for a moderate-intensity statin based on having type 2
diabetes mellitus and being between 40 and 75 years of age. Therefore, rosuvastatin is the best
answer because a dose of 10 mg is a moderate-intensity dose.
A 50-year-old woman presents to your clinic today for routine follow-up on her hypertension,
cholesterol, and type 2 diabetes mellitus. Her mother is alive, but her father passed away at age 55 from a myocardial infarction. She tries to follow a low sugar and low sodium diet. The patient smokes one pack of cigarettes per day but is otherwise healthy. Her lipid panel today is total cholesterol 220 mg/dL (5.69 mmol/L), HDL cholesterol 45 mg/dL (1.16 mmol/L), and
triglycerides 160 mg/dL (1.81 mmol/L).
The patient returns to clinic 12 months after her last visit. She reports she was diagnosed with
peripheral artery disease 6 months ago. Her lipid panel is as follows today: total cholesterol 170mg/dL (4.40 mmol/L), triglycerides 90 mg/dL (1.02 mmol/L), HDL cholesterol 42 mg/dL (1.09
mmol/L), LDL cholesterol 110 mg/dL (2.84 mmol/L). She has been taking atorvastatin 10 mg daily for the last 6 months. According to the 2018 AHA/ACC guideline, what is the next step to optimize this patient’s cholesterol and lower her risk of future CV events?
A. Change atorvastatin to simvastatin 80 mg daily
B. Change atorvastatin to rosuvastatin 10 mg daily
C. Increase atorvastatin to 80 mg daily
D. Add ezetimibe 10 mg daily
Option C: Correct. The patient is indicated for a high-intensity statin based on her diagnosis of
peripheral artery disease, which is a form of clinical ASCVD. Atorvastatin 80 mg is the only
high-intensity statin dose listed that is recommended to prescribe.
Which side effect can be caused by bempedoic acid therapy?
A. Hypertension
B. Hypothyroidism
C. Hyperuricemia
D. Renal failure
Option C: Correct. Bempedoic acid is associated with increasing uric acid levels.
According to the AACE/ACE guidelines, what are the LDL cholesterol and non-HDL cholesterol goals for a patient who is considered extreme risk?
A. Less than 30 mg/dL (0.78 mmol/L) and 60 mg/dL (1.55 mmol/L)
B. Less than 55 mg/dL (1.42 mmol/L) and 80 mg/dL (2.07 mmol/L)
C. Less than 80 mg/dL (2.07 mmol/L) and 100 mg/dL (2.59 mmol/L)
D. Less than 100 mg/dL (2.59 mmol/L) and 130 mg/dL (3.36 mmol/L)
Option B: Correct. The AACE/ACE guidelines recommend an LDL cholesterol goal of less than
55 mg/dL (1.42 mmol/L) and a non-HDL cholesterol less than 80 mg/dL (2.07 mmol/L) for
those considered extreme risk.
Which of the following is considered an ASCVD risk-enhancing factor per the 2018
AHA/ACC cholesterol guideline?
A. hs-CRP greater than 1 mg/L
B. Ankle-brachial index less than 1
C. Premature menopause
D. LDL cholesterol greater than 130 mg/dL (3.36 mmol/L)
Option C: Correct. One of the ASCVD risk-enhancing factors per the 2018 AHA/ACC
cholesterol guideline is a history of premature menopause.
Choose the patient scenario below that meets the FDA-approved indication for icosapent ethyl
as a lipid-lowering therapy to reduce risk of a cardiovascular event.
A. A 40-year-old woman with heterozygous familial hypercholesterolemia (HeFH) taking
atorvastatin 80 mg daily with an LDL cholesterol of 50 mg/dL (1.29 mmol/L)
B. A 60-year-old man with type 2 diabetes mellitus, hypertension, dyslipidemia, and gout taking atorvastatin 80 mg daily with an LDL cholesterol of 70 mg/dL (1.81 mmol/L) and triglycerides of 175 mg/dL (1.98 mmol/L)
C. A 40-year-old man with history of a myocardial infarction 1 year ago receiving atorvastatin 10 mg daily with an LDL cholesterol of 100 mg/dL (2.59 mmol/L) and triglycerides of 200mg/dL (2.26 mmol/L)
D. A 60-year-old woman with hypertension and hypothyroidism receiving atorvastatin 20 mg
daily with an LDL cholesterol of 130 mg/dL (3.36 mmol/L) and triglycerides of 150 mg/dL (1.70
mmol/L)
Option B: Correct. The FDA-approved indication for icosapent ethyl is adjunct to maximally
tolerated statin therapy to reduce the risk of MI, stroke, coronary revascularization, and unstable
angina requiring hospitalization in adult patients with elevated triglyceride (TG) levels (≥ 150
mg/dL [1.70 mmol/L]) and established ASCVD or diabetes mellitus and two or more additional
risk factors for CVD. This patient meets these criteria as they have diabetes plus age and
hypertension risk factors as well as elevated triglycerides.
A 46-year-old man with a history of dyslipidemia and hypertension is taking atorvastatin 40
mg daily (started 1 year ago). His lipid values today are non-HDL cholesterol 156 mg/dL (4.03
mmol/L) and LDL cholesterol 110 mg/dL (2.84 mmol/L). His 10 year ASCVD risk prior to
starting atorvastatin was 9%. The patient complains of mild muscle pain and weakness today with a creatine kinase of 120 U/L (2.00 µkat/L). What would be the most appropriate
intervention?
A. Continue current therapy and monitor his progress
B. Decrease his atorvastatin dose to 20 mg daily and monitor his progress
C. Add fenofibrate 145 mg daily
D. Add niacin ER 500 mg at bedtime
Option A: Correct. Based on the patient’s creatine kinase (CK) not being greater than three times
the upper limit of normal (ULN) and mild symptoms, it is appropriate to continue the patient on
the current statin dose and continue to monitor his muscle symptoms.
A 45-year-old man with a history of hypertension is coming in today for his annual follow-
up. He has a family history of early heart disease with his father having a heart attack at age 50.
His lipid values today are total cholesterol 180 mg/dL (4.65 mmol/L), HDL cholesterol 40
mg/dL (1.03 mmol/L), and LDL cholesterol 110 mg/dL (2.84 mmol/L). He has a 10 year
ASCVD risk score of 7.5%. Which of the following tests are recommended by the AHA/ACC
cholesterol guideline to help decide whether to initiate a statin in this patient?
A. Microalbumin
B. Coronary artery calcium score
C. hs-CRP
D. Apo B
Option B: Correct. In patients who are considered intermediate risk based on their ASCVD risk score and wanting additional tests to help determine who should be considered for a statin, it is recommended to perform a coronary artery calcium score as a deciding factor per the 2018 AHA/ACC cholesterol guideline (see Figure 13–5).
Which of the following statins and doses are considered moderate-intensity statins?
A. Atorvastatin 40 mg daily
B. Pravastatin 20 mg daily
C. Simvastatin 20 mg daily
D. Lovastatin 20 mg daily
Option C: Correct. Simvastatin 20 mg daily is a moderate-intensity statin.
Which type of therapy would be most appropriate for a 40-year-old woman with stage 4 chronic kidney disease and hypertension with a total cholesterol 190 mg/dL (4.91 mmol/L), HDL cholesterol 50 mg/dL (1.29 mmol/L), and triglycerides 550 mg/dL (6.22 mmol/L)?
A. Atorvastatin 80 mg daily
B. Colestipol 2 g daily
C. Vascepa 2 g twice daily
D. Gemfibrozil 600 mg once daily
Option C: Correct. The best recommendation to treat a patient with severe hypertriglyceridemia
(≥ 500 mg/dL [5.65 mmol/L]) and stage 4 chronic kidney disease is to initiate an omega-3-fatty
acid like Vascepa.
A 76-year-old man suffered a stroke 2 years ago and has a history of type 2 diabetes mellitus,
hypertension, and dyslipidemia. He reports he has been on atorvastatin 80 mg daily since his
stroke. His lipid values yesterday were total cholesterol 150 mg/dL (3.88 mmol/L), HDL
cholesterol 45 mg/dL (1.16 mmol/L), triglycerides 120 mg/dL (1.36 mmol/L), and LDL
cholesterol 81 mg/dL (2.09 mmol/L). What is the best recommended lipid-lowering therapy for
this patient based on 2018 AHA/ACC cholesterol guideline?
A. Continue atorvastatin 80 mg daily
B. Add ezetimibe 10 mg daily
C. Decrease atorvastatin to 40 mg daily
D. Add evolocumab 140 mg every 2 weeks
Option B: Correct. The 2018 AHA/ACC guideline recommends in patients with clinical ASCVD
that they should receive a high-intensity statin and continue this if are tolerating beyond the age of 75 years. Further recent data support the additional role of ezetimibe in a poststroke
population over age 75 years in addition to statin therapy when not achieving an LDL cholesterol
threshold of less than 70 mg/dL (1.81 mmol/L).
- Which of the following are considered major risk factors for atherosclerotic cardiovascular
disease?
A. Females greater than 45 years of age
B. Systolic blood pressure greater than 130 mm Hg
C. Current cigarette smoker
D. Males with an HDL cholesterol greater than 50 mg/dL (1.29 mmol/L)
Option C: Correct. The only major risk factor for atherosclerotic disease listed is current
cigarette smoking.
- A high-intensity statin regimen is capable of lowering LDL cholesterol by how much on
average?
A. Greater than or equal to 20%
B. Greater than or equal to 30%
C. Greater than or equal to 50%
D. Greater than or equal to 70%
Option C: Correct. A high-intensity statin regimen is capable on average of lowering LDL
cholesterol by greater than or equal to 50%.
