Preventative Medicine V

Question 1

CVD guidelines.

Answer 1

USPSTF, no hx CHD, using non-traditional risk factors*:  Insufficient evidence:
-hs-CRP
-ankle-brachial index
-leukocyte count
-FBG level
-periodontal disease
-carotid intima-media thickness
-coronary artery calcification score on electron-beam CT
-homocysteine level
-lipoprotein(a) level
USPSTF, using EKG (resting or exercise):
-Low risk adults = Grade D
-Intermediate or high risk adults = insufficient evidence

Question 2

Carotid artery stenosis guidelines.

Answer 2

USPSTF = Grade D:

• 10% of ischemic strokes caused by CAS
• 1% of CAS is asymptomatic
• No incremental overall benefit of CEA, stenting, or intensification of medical therapy
• Potential for overall benefit limited by low prevalence and harms

Question 3

Hyperlipidemia guidelines.

Answer 3

USPSTF:
< 20, Insufficient evidence.
-Primary prevention
–Age 40-75, no hx CVD, ≥ 1 CVD risk factor, & 10-yr CVD risk ≥ 10% = low-mod dose statin (Grade B)
—If CVD risk 7.5-10%, Grade C
–Age 76+, no hx CVD = Insufficient evidence

Question 4

HTN Children and adolescents guidelines.

Answer 4

AAP
-≥ 3 y/o = every health care episode
NHLB 
-3-17 y/o = annually
Bright Futures, AHA
-During annual well child visits beginning at age 3

Question 5

HTN adult guidelines.

Answer 5

USPSTF

• Age 18+, Grade A
• 18-39 y/o = every 3-5 years
• ≥ 40 y/o = annual screening
• Increased risk for HTN = annual screening
• -High-normal BP (130-139/85-89 mm Hg)
• -Overweight or obese
• -African American

Question 6

AAA guidelines.

Answer 6

Men:
65-75 y/o who have ever smoked	
One-time screening with U/S = Grade B
65-75 y/o who have never smoked
Selectively offer screening rather than routinely screening = Grade C
Women: 
65-75 y/o who have ever smoked
Insufficient evidence
65-75 y/o who have never smoked
Screening not recommended = Grade D

Question 7

Aspirin prophylaxis guidelines.

Answer 7

USPSTF, Aspirin use to prevent CVD and colorectal cancer:

• 50-59 y/o adults, Grade B if:
• -≥ 10% 10-year CVD risk,
• -Not at risk of bleeding
• -Have a life expectancy of at least 10 years
• -Willing to take low-dose aspirin daily for at least 10 years
• 60-69 y/o with a ≥ 10% 10-yr CVD risk, Grade C:
• -More likely to benefit if not at increased risk of bleeding, life expectancy is at least 10 years, willing to take low-dose aspirin daily for at least 10 years
• Adults younger than 50 y/o
• -Insufficient evidence
• Adults ≥ 70 y/o
• -Insufficient evidence

Question 8

Aspirin prophylaxis guidelines.

Answer 8

USPSTF, Aspirin use to prevent CVD and colorectal cancer:

• 50-59 y/o adults, Grade B if:
• -≥ 10% 10-year CVD risk,
• -Not at risk of bleeding
• -Have a life expectancy of at least 10 years
• -Willing to take low-dose aspirin daily for at least 10 years
• 60-69 y/o with a ≥ 10% 10-yr CVD risk, Grade C:
• -More likely to benefit if not at increased risk of bleeding, life expectancy is at least 10 years, willing to take low-dose aspirin daily for at least 10 years
• Adults younger than 50 y/o
• -Insufficient evidence
• Adults ≥ 70 y/o
• -Insufficient evidence

Question 9

Cardiovascular disease risk factors and calculator.

Answer 9

Assess major modifiable risk factors:
Diet
Smoking
Hypertension
Dyslipidemia
Obesity
Physical activity
Diabetes mellitus
Risk calculator:
--ACC/AHA, 10-yr risk of ASCVD
Age
Gender
Race
Cholesterol (total, HDL)
Systolic/diastolic BP
On tx for BP
Diabetes
Smoker 
≥ 7.5% = increased risk

Question 10

Colorectal cancer guidelines.

Answer 10

USPSTF:

• Grade A = adults age 50-75 y/o
• Grade C = adults age 76-85 y/o
• -Most appropriate if healthy enough to undergo tx if cancer detected, and no comorbid conditions significantly limiting life expectancy
• -Greater benefit if never been screened

Question 11

Prostate cancer guidelines.

Answer 11

USPSTF (2012)*:
-Grade D
-Benefits
Large US study:  no benefit
Large European study (study with the highest reported benefit):  no more than 1:1000 avoid death by screening
-Harms 
False-positives
Biopsy side effects
Overtreatment
Side effects from treatment:  ED, urinary incontinence, bowel control problems, deaths or serious complications from surgery
-Current USPSTF draft recommendations
Grade C:  age 55-69, individualized decision making; clinicians should inform about benefits/harms
Grade D:  men age 70+

Question 12

Skin cancer guidelines.

Answer 12

USPSTF:

-Insufficient evidence

Question 13

Breast cancer guidelines: (mammograms)

Answer 13

Average risk:
USPSTF:
-Age 40-49, individualize (grade C)
-Every 2 years, age 50-74 (grade B)
ACOG:
-Every year, age 40-74
≥ age 75, individualize

Question 14

Cervical cancer guidelines:

Answer 14

USPSTF:
Screen women from 21 to 65. Do not screen under 21.
HPV testing Dont do it under 30.

Question 15

Lung cancer guidelines.

Answer 15

USPSTF:

• Grade B: Adults aged 55-80 with a history of smoking.
• -Annual screening with low-dose CT if there is a 30-pack-year smoking history and the patient currently smokes or has quit within the past 15 years
• -Discontinue screening once the person has not smoked for 15 years, or develops a health problem substantially limiting life expectancy or the willingness to have curative lung surgery

Question 16

Thyroid disorders guidelines.

Answer 16

Thyroid disorders
Insufficient evidence
Hypothyroidism:
AAFP: periodic assessment in older women
ACP: women over 50
ATA/AACE: those at risk for hypothyroidism & anybody over age 60
At risk: personal history of type 1 diabetes or other autoimmune disease, family history of thyroid disease, history of neck radiation to the thyroid, history of thyroid surgery)
Thyroid cancer:
Grade D

Question 17

Osteoporosis guidelines.

Answer 17

Grade B: women ≥ 65 y/o & younger women whose fracture risk is equal to or greater than that of a 65 y/o white woman who has no additional risk factors.
Insufficient evidence for men.