Mehl. Risk factors 1 (cardio) 03-26 (1) Flashcards
(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?
smoking cessation
(1) When in doubt, “smoking cessation” is the most common overall answer on NBME/USMLE for the #1 way to improve general health.
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.
(2) 67F + diabetic + smoker + HTN; Q asks which of the following is biggest risk factor for developing an MI in this patient?
Diabetes
(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.
Diabetes (I and II), followed by smoking, followed by HTN
(2) most common risk factor in the population for atherosclerosis?
HTN
(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.
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(2) risk factor most acceleratory for atherosclerosis of the carotid arteries?
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.
(2) If Q asks about how to decrease peri- or post-operative MI risk, answer on nbme?
answer will be smoking cessation on NBME. This is presumably because smoking cessation acutely improves blood flow + oxygen utilization at myocardium.
(3) 67F + smoker + HTN + high BMI; Q asks biggest risk factor for developing an MI in this patient?
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.
(4) 60F + diabetic + HTN + smoker + about to undergo hip surgery; Q asks for the best way to reduce perioperative MI risk?
smoking cessation
(4) number 1 to reduce perioperative MI risk?
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.
(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?
smoking cessation
(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).
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(6) 60F + Hx of MI 5 years ago + diabetic + smoker + HTN; Q asks number-one risk factor for an MI occurring in this patient?
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.
(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?
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.
(8) Patient has autoimmune disease (i.e., SLE, RA, etc.); question wants to know how to decrease recurrence of flares?
smoking cessation.
(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)?
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.
(10) 11F + rhinoconjunctivitis past month; Q asks what to ask parents about -> answer =?
“recent pets in household”;
if recent allergy-like presentation in a patient with no prior Hx, inquire about pets.
(11) 55M + gangrene of the fingers + HTN + drinks alcohol and smokes; Q wants to know #1 way to improve this patient’s condition?
smoking cessation;
diagnosis is Buerger disease (thromboangiitis obliterans), which is idiopathic digital gangrene, generally in middle-age men who are heavy smokers.
very HY !!!!!!!!!!!!!!!!!!! (12) 66M + experiences stroke + has Hx of hypertension and smoking; Q asks #1 way to decrease risk of recurrent stroke?
answer = lisinopril; smoking cessation is wrong answer.
!!!!!!!! (12) what has higher risk for stroke: HTN or smoking?
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.
!!!!!!!! (12) The order of risk factors for stroke on NBME/USMLE is: ?3
atrial fibrillation (AF) –> HTN –> smoking.
!!!!!!!! (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.
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.
!!!!!!!! (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.
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.
!!!!!!!! (12) It is specifically hypertension that affects the carotids.
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(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?
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.
(13) When to do carotid endarterectomy?2
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%.
(13) If patient is under endarterectomy % thresholds, the treatment = the triad of drugs?
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.
(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 = ?
management of hypertension”; smoking cessation is wrong answer.
(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.”
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.
(15) 79M + irregularly irregular rhythm on ECG + history of HTN; Q asks most important risk factor for stroke in this patient?
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.
(15) AF can cause left atrial mural thrombi that launch off to the brain/eye; HTN causes carotid atheromatous plaques that launch off.
AF is most common in patients over 75, or occasionally in select patient groups such as those with hyperthyroidism.
(16) 79M + atrial fibrillation + HTN; Q wants to know best way to decrease stroke risk in this patient?
Answer = warfarin; aspirin is wrong answer;
(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
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.
