Week 1 HTN, Dyslipidemia, Obesity, Metabolic Syndrome

Question 1

Which medications are associated with weight gain? (Select all that apply)

A. Antibiotics

B. Antidepressants

C. Anticonvulsants

D. Insulin analogs

E. Antihistamines

Answer 1

B. Antidepressants

C. Anticonvulsants

D. Insulin Analogs

E. Antihistamines

Question 2

High intensity statin (lowers LDL-C > 50%)

Answer 2

Rosuvastatin 20mg

Question 3

Low intensity statin (lowers LDL- C < 30%)

Answer 3

Pravastatin 20mg

Question 4

Moderate intensity statin (lowers LDL-C by 30-50 %

Answer 4

Atorvastatin 20mg

Question 5

A patient who is taking a statin drug to treat dyslipidemia has begun a diet and exercise program. The patient reports new onset of muscle pain several weeks after beginning therapy. What is the initial action by the provider?

A. Discontinue the statin drug immediately

B. Obtain a creatine kinase level

C. Prescribe acetaminophen or ibuprofen

D. Recommend reducing exercise intensity

Answer 5

B. Obtain a creatine kinase level

A potential serious side effect of statin drugs is drug-induced myopathy. Patients who report new-onset muscle pain should have creatine kinase levels evaluated. If this is elevated, the drug should be stopped, and renal function should be evaluated. It is not safe to assume that the muscle pain is related to the exercise until CK levels are determined.

Question 6

A 13-year-old Native American female has a body mass index (BMI) at the 90th percentile for age. The primary care pediatric nurse practitioner notes the presence of a hyperpigmented velvet-like rash in skin folds. The child denies polydipsia (abnormally great thirst), polyphagia (excessive eating), and polyuria (excessive urination). The nurse practitioner will take what action?

A. Counsel the child to lose weight to prevent type 2 diabetes

B. Diagnose type 2 diabetes if the child has a random glucose of 180 mg/dL

C. Order a fasting blood sample for a metabolic screen for type 2 diabetes

D. Refer the child to a pediatric endocrinologist

Answer 6

C. Order a fasting blood sample for a metabolic screen for type 2 diabetes

This child has three risk factors for type 2 diabetes: Native American ethnicity, overweight, and acanthosis nigricans (a skin condition that causes a dark discoloration in body folds and creases). The PNP should perform metabolic screening on a fasting blood sample to diagnose this. Lifestyle changes may be necessary to control the disease if diagnosed, but this child may already have the disease, and management options aren’t clear until the diagnosis is made. Diagnosis is based on a random glucose >200 mg/dL. It is not necessary to refer this child until a diagnosis is made.

Question 7

Elevated blood pressure in response to stress (especially in the doctor’s office) is called “white-coat hypertension.”

Which of the following statements is true about white-coat hypertension?
(select all)

A. As long as the majority of blood pressure readings are normal, the patient does not require treatment because there is no increased risk of adverse cardiac outcomes.

B. Patients with white-coat hypertension have an intermediate risk for adverse outcomes when compared with patients with normal blood pressure and those with chronically elevated blood pressure.

C. White-coat hypertension is more common in young patients.

D. Patients with white-coat hypertension have an elevated left ventricular mass when compared to patients with normal blood pressures.

Answer 7

Both B & D

B. Patients with white-coat hypertension have an intermediate risk for adverse outcomes when compared with patients with normal blood pressure and those with chronically elevated blood pressure.

D. Patients with white-coat hypertension have an elevated left ventricular mass when compared to patients with normal blood pressures.

Patients with white coat hypertension have outcomes that are intermediate between normotensive and hypertensive patients. In addition, they have an elevated left ventricular mass. Surprisingly, white coat hypertension is more common in the elderly.

Question 8

A 35-year-old male presents to the office with upper respiratory symptoms. He is taking no medications except for a bit of pseudoephedrine for his cold. You notice when looking at his vital signs that his blood pressure is 180/106 mm Hg. Repeat measurement confirms that the blood pressure is elevated at 175/105 mm Hg.

A. Start a chronic antihypertensive since he is at risk for a stroke within the next couple of days with a blood pressure at this level.

B. Administer clonidine in the office to reduce the blood pressure to a safe level of about 150/100 mm Hg.

C. Watch the patient over the next two weeks and get additional blood pressure readings before deciding what to do and instruct him to discontinue pseudoephedrine.

D. Schedule the patient for outpatient labs and electro-cardiogram.

E. Fire the patient from your practice. He’s messing up your quality measures.

Answer 8

C. Watch the patient over the next two weeks and get additional blood pressure readings before deciding what to do and instruct him to discontinue pseudoephedrine.

The diagnosis of hypertension requires two elevated blood pressures on two different occasions. This patient’s elevated blood pressure could be situational, related to decongestants and current illness (though decongestants only increase systolic blood pressure by 2–3 mm Hg if at all). Neither “A” nor “B” is correct because a blood pressure of 175/105 mm Hg does not pose a risk of acute stroke, and the pressure need not be lowered acutely unless there is evidence of end-organ injury (e.g., angina, heart failure, hypertensive encephalopathy). “D” is incorrect because you cannot definitively establish that this patient has hypertension based on only one in office blood pressure measurement. As for “E”…really? Is this why we went into medicine?

Question 9

The ambulatory blood pressure monitor reveals that the patient’s blood pressure is >140/90 mm Hg more than 40% of the time, indicating that he is indeed hypertensive.

The initial evaluation of the hypertension includes the following:

A. History, physical, CBC, urinalysis, glucose, BUN, creatinine, electrolytes, ECG, and lipids

B. History, physical, CBC, uric acid, glucose, BUN, creatinine, electrolytes, and lipids

C. History, physical, CBC, urinalysis, glucose, BUN, creatinine, electrolytes, ECG, lipids, and echocardiography

D. History, physical, and labs only as indicated by history and physical

Answer 9

A. History, physical, CBC, urinalysis, glucose, BUN, creatinine, electrolytes, ECG, and lipids

History, physical, CBC, urinalysis, glucose, BUN, creatinine, electrolytes, ECG, and lipids are the generally agreed-upon initial workup of the hypertensive patient. “C” includes echocardiography, which is not recommended as part of the routine evaluation but may be indicated if signs of cardiac disease are present.

Question 10

You start a 35-year-old male on chlorthalidone for hypertension, but his blood pressure does not respond at a dose of 12.5 mg/day (have your patients cut the 25-mg tabs in half). His blood pressure on follow-up is 148/96 mm Hg.

A. Push his chlorthalidone to 25 mg daily before starting another medication

B. Stop the chlorthalidone and start another medication

C. Rely on exercise and diet to normalize the blood pressure

D. Start a second drug , before, you have maximized the dose of the first drug

E. Start a workup for secondary causes of hypertension

F. A or D

Answer 10

F. A or D
A. Push his chlorthalidone to 25 mg daily before starting another medication
D. Start a second drug , before, you have maximized the dose of the first drug

Per the JNC 8 guidelines, both “A” and “D” are acceptable strategies; you could push up the dose of a first drug or add a second drug. There is a lack of randomized controlled trials to guide these recommendations. JNC 8 urges us to tailor therapy based on individual circumstances, clinician and patient preference, and drug tolerability. Low-dose chlorthalidone (12.5 mg) provides the greatest blood pressure reduction per mg of drug, and there is little clinical benefit of utilizing >25 mg daily of HCTZ or chlorthalidone. Higher doses are associated with increased adverse effects with minimal clinical gain in hypertension management. “B” is incorrect because a patient with this level of blood pressure elevation will generally require more than one drug to achieve a normalized blood pressure. “C” is incorrect because the majority of patients are unable to maintain an adequate diet or exercise regimen to effectively treat blood pressure. Exercise and dietary change are certainly laudable goals and should be encouraged in all patients. However, they are not likely to normalize blood pressure in most hypertensive patients. “D” is also correct as it represents one of the acceptable JNC 8 guideline strategies to dose antihypertensive drugs. “E” is incorrect since this patient has not yet proven to be resistant to treatment.

Question 11

The patient returns to your office with blood pressures measured six times over a period of two weeks at a local pharmacy. Only three of the six readings suggest that the patient is hypertensive. The patient states that the elevated blood pressures were while he was under stress at work.

A. Start an antihypertensive

B. Send the patient for a 24-hour ambulatory blood pressure measurement

C. Don’t worry about the blood pressure since half of the readings were within a normal range

D. Get a nephrology consult to help in decision making

Answer 11

B. Send the patient for a 24-hour ambulatory blood pressure measurement

One way to determine if a patient with contradictory readings is hypertensive is to perform 24-hour ambulatory blood pressure monitoring. This can be useful in patients who have elevated blood pressures in the office but not at home or vice versa. It can also be used if you do not trust the blood pressure readings taken outside of your office. “A” is incorrect since we have not yet established that this patient is hypertensive. “C” is incorrect since we have not yet established that this patient is not hypertensive. “D” is incorrect because you are smarter than that and should be able to work through this kind of case yourself!

Question 12

All of the following drugs are associated with weight gain and an increased risk of obesity except:

A. Gabapentin/Pregabalin

B. Topiramate

C. Valproic acid

D. Olanzapine

E. Glipizide

Answer 12

B. Topiramate

Topiramate may actually help patients lose weight. In fact, it is one of the components of the weight loss drug Qsymia® (phentermine/topiramate).

Question 13

Regarding definition and classification of obesity, which of the following is true?

A. Obesity is defined as BMI ≥25 kg/m, 2

B. Severe obesity is defined as BMI >30 kg/m, 2

C. Underweight is defined as BMI <20 kg/m, 2

D. Obesity is defined as BMI ≥30 kg/m, 2

E. Malnourished supermodel status is defined as BMI <30 kg/m2

Answer 13

D. Obesity is defined as BMI ≥30 kg/m, 2

The calculation for BMI is as follows:

BMI(kg/m2) = weight(kg)/[height(m)]2.

Question 14

A patient wonders which popular diet she should use to lose weight.

You let her know that the most effective popular diet is:

A. Low carbohydrate (Atkins diet)

B. Low fat (Ornish diet)

C. Low glycemic load diet (Zone diet)

D. High protein (Paleo diet)

E. No one particular diet is more effective than others for weight loss. The key to success is choosing a diet that you can maintain.

Answer 14

E. No one particular diet is more effective than others for weight loss. The key to success is choosing a diet that you can maintain.

Any diet you can stick to seems to work. There does not seem to be any advantage to one diet over another for weight loss (except for making the proprietors wealthy). For example, Weight Watchers may have a bit better success because of peer pressure, weekly meetings, and motivational techniques (BMJ. 2011;343:d6500). But any diet that you can maintain long-term will work. Of note, the common belief that maintaining a 3,500 calorie weekly deficit will result in 1 lb (0.45 kg) of weight loss per week is a myth. But reducing calorie intake by 100 calories per day may lead to a gradual weight loss of approximately 10 lb over 1 to 3 years (Am Fam Physician. 2015;91(9):634–638).

Question 15

As your patient is not meeting with an ounce of success (literally), you engage in a discussion about weight loss pharmacotherapy.

A. Levothyroxine (Synthroid, Levoxyl)

B. Methylphenidate (Ritalin)

C. Orlistat, (Xenical, Alli)

D. Paroxetine (Paxil)

Answer 15

C. Orlistat, (Xenical, Alli)

Drug therapy is considered appropriate as an add-on to lifestyle management for people with a BMI of 30 kg/m2 or greater, or a BMI of 27 kg/m2 or more who already have a comorbid condition such as diabetes, hypertension, or hyperlipidemia. Of the choices listed, only orlistat is indicated by the FDA to treat obesity (more below). “A” and “B” are incorrect. Although patients treated with these medications might lose weight as a side effect, obesity alone is not an indication for levothyroxine or methylphenidate. Paroxetine (“D”) may be associated with weight gain and is not indicated for obesity.

Question 16

After collecting a history and physical, which of the following is the most appropriate next step in the evaluation of weight gain in a 30 year-old obese female?

A. Refer for a sleep study

B. Check urinary free cortisol level

C. Draw blood for thyroid-stimulating hormone level

D. Evaluation for adrenal adenoma causing Cushing disease

E. Cast your gaze down, realizing that affecting behavior change is difficult

Answer 16

C. Draw blood for thyroid-stimulating hormone level

Because of her obesity, this patient is also at risk for sleep apnea, diabetes, hypertension, and hyperlipidemia. These concerns will need to be addressed. However, her chief complaint is weight gain, which could certainly be due to an underlying disease. Although in most overweight patients a cause for weight gain is not found, the physician is obligated to search for potentially treatable causes of weight gain, including hypothyroidism. The symptoms of hypothyroidism are often nonspecific and include weight gain and fatigue. That said, an exhaustive search for underlying causes of obesity is not required for the vast majority of patients. History, exam, and limited laboratory evaluation should be sufficient for most patients.

Question 17

A new patient presents for his annual examination and has some questions about cardiovascular disease risk. He also wants to chat about his favorite sports team (Iowa Hawkeyes, we hope), but you gently steer him back to the matter at hand.

The following are all considered cardiac risk factors when calculating cardiac risk and the need for statins per the ACC/AHA calculator (http://www.cvriskcalculator.com), except:

A. Age

B. A relative with early heart disease

C. Smoking

D. Hypertension

E. Gender

Answer 17

B. A relative with early heart disease

The ACC/AHA calculator includes the following risk factors for CAD: age, gender, “race,” total cholesterol, HDL cholesterol, systolic and diastolic BP, diabetes, smoking and whether or not one is being treated for hypertension. Unlike many Caribbean resort destinations, the calculator is not all-inclusive. Many known risk factors for heart disease (e.g., family history, obesity) are not taken into account. The risk calculator is a tool; you must continue to apply clinical judgment. Also, the calculator, as well as the entire guideline, is not meant to be used to manage all forms of dyslipidemias. Remember from earlier in this chapter that peripheral vascular disease is considered a CAD equivalent.

Question 18

You obtain laboratory tests. The patient has normal electrolytes and the following cholesterol panel: Total cholesterol 175 mg/dL, LDL 110 mg/dL, HDL 35 mg/dL, and triglycerides 150 mg/dL. He is a 55-year-old African-American male, nonsmoker, and nondiabetic who takes no medications. His systolic blood pressure is 132/85 mm Hg. You plug all his data into the ASCVD risk calculator and generate a 10-year ASCVD risk of 7.5%.

Given the ASCVD risk you calculated, and being consistent with the 2018 ACC/AHA guideline, you recommend:

A. No changes, keep calm and carry on

B. A treadmill stress test

C. A high fiber diet

D. Low-intensity statin therapy (e.g., simvastatin 10 mg daily)

E. Moderate-intensity statin therapy (e.g., atorvastatin 10–20 mg daily)

Answer 18

E. Moderate-intensity statin therapy (e.g., atorvastatin 10–20 mg daily)

Did you think this patient was a candidate for moderate statin therapy prior to this guideline? If not, you are not alone. The 2018 ACC/AHA guideline has changed the way we determine risk, expanding the use of statins. Patients whose 10-year ASCVD risk is 7.5% or greater should be on moderate-to-high-intensity statin therapy. As noted above, we have dueling guidelines. Of course, you should discuss the pros and cons with every patient.

Question 19

Your astute patient appears to be goal-oriented and asks you what his target LDL should be. You reply:

A. “Targets are so 2012. The goal is to get you on a moderate-to-high-intensity statin. There is no specific LDL goal number.”

B. “Your target LDL is <100 mg/dL.”

C. “Your target LDL is about 70 mg/dL.”

D. “Your target LDL is simply as low as we can get without causing rhabdomyolysis…well, maybe just a little rhabdo would be OK.”

Answer 19

A. “Targets are so 2012. The goal is to get you on a moderate-to-high-intensity statin. There is no specific LDL goal number.”

The 2018 ACC/AHA guideline does not recommend treating to specific LDL targets. Instead, appropriate statin therapy should be selected based on risk category as previously indicated. Your goal is to get the patient to a maximal dose of statin and not a specific LDL. That said, the LDL should be reduced by 50% even if that is a starting point of 400 mg/dL and the patient ends up at 200 mg/dL.

Question 20

According to the 2018 ACC/AHA Blood Cholesterol Guideline, all of the following automatically qualify as patients who would benefit from statin therapy except:

A. A patient with known cardiovascular disease

B. A 40-year-old patient with an LDL of 200 mg/dL

C. A 55-year-old diabetic patient with an LDL of 130 mg/dL

D. A 55-year-old nondiabetic patient without known cardiovascular disease whose 10-year ASCVD risk is calculated as 10%

E. A 35-year-old smoker with hypertension

Answer 20

E. A 35-year-old smoker with hypertension

The 35-year-old patient might be a candidate for a statin (HMG-CoA reductase inhibitor) but is not an automatic candidate based on the information given. All other options describe patients who would benefit from statin therapy according to the 2018 ACC/AHA guideline. The 2018 ACC/AHA guideline relies on a risk calculator for primary prevention. See Table 2-11 for a summary of the 2018 cholesterol guidelines. It is important to note that while the ACC/AHA guideline recommends moderate-to-high-intensity statin therapy starting at a 10-year ASCVD risk score of 7.5%, the USPSTF recommends low-to-moderate dose statin therapy at an ASCVD risk score of 10%. We cannot know for sure what answer the ABFM would use for the test, but they usually side with the USPSTF.

Question 21

RF for CAD

Answer 21

First-degree male relative with CAD or sudden death at age < 55 or first-degree female relative with CAD or sudden death at age < 65

Smoking

HDL < 40 mg/dL (HDL > 60 mg/dL is considered protective)

Diabetes

Hypertension (>140/90) or on antihypertensives

Age: males >45, females >55

Elevated LDL

Question 22

What does the USPSTF recommend in terms of screening for lipid disorders?

A. Screen all adults annually starting at age 25

B. Screen men age 35 years and older

C. Screen women age 45 years and older

D. Universal screening of all patients age 40 to 75

Answer 22

D. Universal screening of all patients age 40 to 75

USPSTF updated its lipid testing recommendations in 2016. Here is a summary:

Screen patients 40 to 75 years of age without CAD. Treatment is suggested for those 40 to 75 years of age with elevated lipids and one other risk factor for CAD (risk factors for this purpose include (LDL-C > 130 mg/dL or HDL-C < 40 mg/dL), diabetes, hypertension, and smoking) and >10% ten-year risk of having a cardiac event based on the ACA calculator.

Use low-to-moderate dose statins. For those with a risk of 7.5% to 10%, discuss pros and cons with the patient—which of course you do with all patients anyway (JAMA. 2016;316(19):1997–2007). Note that the benefit of lipid treatment outweighs the risk of diabetes (which can be seen with statins).

Question 23

The patient then asks you about something he read about “crap.” A light bulb goes off and you realize he wants to know about C-reactive protein (CRP).

Which of the following best represents the role of CRP in cardiac disease in 2015?

A. CRP should be measured in all patients in whom cardiac disease is suspected

B. CRP should be measured only in patients with intermediate cardiac risk factors (e.g., those with a 10-year risk of CAD of 10–20%)

C. CRP should be measured in patients with known heart disease in order to monitor inflammation and risk

D. CRP should be measured in low-risk (<10% risk of CAD in next 10 years) patients who have no known cardiac disease. An elevated CRP suggests that these patients should be treated with a lipid-lowering therapy

E. CRP has not been shown to be useful and does not contribute significantly to cardiac risk stratification

Answer 23

E. CRP has not been shown to be useful and does not contribute significantly to cardiac risk stratification

Although, high-sensitivity CRP (hsCRP) was initially thought to be a possible biomarker for cardiac risk assessment, it has been shown to be of marginal benefit. The use of hsCRP led to minimal reclassification of patients (a maximum of 11% of intermediate patients were reclassified in one study). The Class IIa recommendation to use hsCRP was published by the AHA in 2003, prior to further studies that have questioned its usefulness.

Question 24

You advise your patient to start atorvastatin 20 mg daily. You check baseline transaminases, which are normal. When your patient returns 3 months later and sees your partner (because you took a “vacation” to study for the board examination), she checks his lipids and transaminases out of habit. If only you had been there! You know that the FDA no longer recommends periodic liver enzyme testing while on a statin. Statin-related hepatotoxicity is an idiosyncratic reaction that is extremely rare and completely unpredictable, so there is no point in routinely checking transaminases. Well, your partner didn’t get the memo, and you return to find your patient’s ALT and AST have both doubled while on atorvastatin and are now almost twice the upper limit of normal for your lab.

When you find transaminases are twice the upper limit of normal while on a statin, the proper response is to:

A
Stop the statin because of the elevated liver enzymes

 B
Start a different statin since this is not a “class effect”

C
Continue the statin and consider other causes for the elevated liver enzymes

D
Add cholestyramine to help ease the burden on the liver

E
Refer for liver biopsy to rule out other causes of elevated liver enzymes

Answer 24

C
Continue the statin and consider other causes for the elevated liver enzymes

Statins can be continued as long as the elevation of liver enzymes is less than three times the upper limit of normal. Never assume that this is a drug effect if there is a reason to believe that the patient could have another disease, such as hepatitis C.

You are compelled to perform the requisite history and physical examination to assess for other causes of liver disease. In the course of your investigations, other labs and imaging may be in order. However, liver biopsy (“E”) would be taking your fiduciary duty to the extreme. “A” is incorrect since the levels are only two times the upper limit of normal. “B” is incorrect for two reasons. First, there is no need to act to change the drug at this point. Second, elevated liver enzymes are a class effect. “D” is incorrect because you do not need to add another drug at this time, and cholestyramine will do nothing to “ease the burden on the liver,” whatever that means.

Question 25

After a thorough history, examination, appropriate lab and imaging tests, you determine that the liver enzyme elevation was due to fatty infiltration. A month later the enzymes have come down to the upper limits of normal. When you see your patient back, he complains of pain and tenderness in his legs, shoulders and back. He also reports generalized fatigue and weakness. What is the most appropriate next step in the evaluation and management of this complaint? A Stop his atorvastatin and replace it with rosuvastatin B Double the dose of atorvastatin C Check liver enzymes D Check creatine phosphokinase (CPK) level E Start coenzyme-Q10 (ubiquinone)

Answer 25

D Check creatine phosphokinase (CPK) level This patient is presenting with symptoms that may be attributable to statin-induced myopathy. Statins have been associated with myalgia and rhabdomyolysis. Prior to making any decisions about therapy, the next step would be to confirm your suspicions by checking the CPK level. If this patient has statin-induced muscle symptoms, he is unlikely to improve by switching to rosuvastatin (“A”); hence, increasing the statin dose (“B”) is the wrong thing to do. While it may be reasonable to check liver enzymes (“C”) due to his complaint of fatigue, myopathy is more likely, given his constellation of symptoms. Of course, in your real medical practice, you could order liver enzymes and CPK, but an examination is not real life! Finally, “E” is incorrect. Coenzyme Q10 has not been shown to prevent or treat statin-related myopathy (Mayo Clin Proc. 2015;90:24). But vitamin D may be useful in patients who are deficient.

Question 26

You check a CPK level, and it is … normal. Darn. You thought you had this mystery wrapped up. From this normal CPK, you can conclude that: A He does not have statin-induced myopathy since the CPK is within normal limits B His fatigue and aches are a manifestation of depression and sleep disturbance C You can safely increase the dose of his statin D He still may have statin-induced myopathy despite a normal CPK E Your lab has a serious quality control issue

Answer 26

D He still may have statin-induced myopathy despite a normal CPK He still may have statin-induced myopathy despite a normal CPK, so “A” is incorrect. There are several crossover trials that demonstrate myopathy in patients with normal muscle enzymes. The mechanism is thought to be a mitochondrial dysfunction. “B” is incorrect, and the reverse may actually be true (myopathy causing poor sleep and anhedonia). “C” is incorrect because he may indeed have a myopathy, and a trial off one or both drugs is warranted. Remember that gemfibrozil (and less so fenofibrate), which you might prescribe for hypertriglyceridemia, interact with statins to increase the risk of statin-induced myopathy/rhabdomyolysis. Remember also that there is no evidence that treating with gemfibrozil or fenofibrate improves cardiovascular outcomes.

Question 27

You stop his atorvastatin. A few weeks later, he returns and feels great! You consider starting a different agent to treat his lipids. Which of the following is classified as a bile acid sequestrant? A Ezetimibe B Colestipol C Colesevelam D B and C E All of the above

Answer 27

D B and C: Colestipol & Colesevelam Ezetimibe (Zetia) is not a bile acid sequestrant but rather reduces cholesterol absorption by blocking at the brush border of the small intestine. This is a mechanism that is different from any of the other lipid-lowering agents. It is relatively safe but expensive and less potent than the statins. You could also try pravastatin and fluvastatin, which are less likely to cause myopathy.

Question 28

Side effects of ezetimibe include which of the following? A Diarrhea B Arthralgia C Angioedema D Liver enzyme elevation E All of the above

Answer 28

E All of the above “C” deserves special mention. As with ACE inhibitors, angioedema has been reported with the use of ezetimibe during post-marketing research. The rate of occurrence is not known. However, it can be life-threatening although no deaths have been reported to date. All of the other side effects are known to occur at a rate greater than with placebo.

Question 29

Your patient is now OK taking maximal dose of a statin, but he has questions about a “cholesterol shot” his friend is taking. Apparently, his friend’s LDL is 300—kind of high. You assume that he is talking about a PCSK9 (proprotein convertase subtilisin kexin type 9) inhibitor, which prevents the binding and the degrading of LDL receptors (thus, there are more LDL receptors to uptake LDL from the blood). The indications for the use of a PCSK9 inhibitor (Praluent® [alirocumab] and Repatha® [evolocumab]) in a patient on statins includes which of the following? A Ongoing angina regardless of the percent decrease of LDL on a maximal dose of a statin B Less than a 50% reduction from baseline of LDL after maximal dose statin + ezetimibe C An absolute LDL of >190 mg/dL after maximal dose statin regardless of the starting LDL D A cardiovascular event while on a maximal dose statin plus a bile acid sequestrant

Answer 29

B Less than a 50% reduction from baseline of LDL after maximal dose statin + ezetimibe Indications for the use of a PCSK9 inhibitor include the following: (1) Failure to reduce the baseline LDL by 50% on a maximal dose of a statin andezetimibe, or (2) a patient who has a cardiovascular event while on a statin plusezetimibeand an LDL of ≥50 mg/dL (not a bile acid sequestrant as in “D”), or a very high LDL secondary to familial hypercholesterolemia. These drugs are expensive (>$10,000/year), and prevent one cardiovascular even for every 74 patients treated for 2 years.

Question 30

A 15-year-old pale Caucasian female returns for her annual well-child check and sports physical. She is well-known to your clinic, and over the years she has steadily gained weight. Her parents and a younger sibling are overweight, and now she has become obese by measure of the pediatric BMI percentages. In recent years, you have become more diligent with watching the BMI on her growth curve. She is aware of her weight problem yet has not voiced any plan for attempting weight loss. What defines “obesity” in adolescence? A. A BMI in the 85th to 94th percentile for age-sex-and-height-specific measures B. A BMI ≥95th percentile for age-sex-and-height-specific measures C. The child has the appearance of being heavy D. The child complains of being fat or overweight E. BMI >35 kg/m2

Answer 30

B. A BMI ≥95th percentile for age-sex-and-height-specific measures A BMI at or above the 95th percentile is considered “obese.” A BMI in the range of 85th to 94th percentiles is considered “overweight.” The use of BMI allows for an objective measure, and although not perfect, can give a picture on the growth curve to patients and parents where they stand relative to age-sex-and-height-related norms. Strict BMI numbers (as in “E”) are not applicable to children and adolescents. A subjective concern about weight (“D”) is important but does not necessarily always warrant further evaluation.

Question 31

Her obesity is discussed openly during the office visit. As expected, she is ashamed and embarrassed about her weight gain. She admits to not knowing what to do and she asks if anything can be done to quickly lose weight. Which of these medications would you recommend now as a first-line therapy for weight loss? A. Topiramate (Topamax) B. Bupropion (Wellbutrin) C. Orlistat, (Xenical) D. Metformin (Glucophage) E. None of the above

Answer 31

E. None of the above No medication is approved for children or adolescents as a first-line therapy. Antidepressants are not helpful if used primarily for weight loss. If there is comorbid depression, which is more common in obese children, a “weight loss” or “weight neutral” antidepressant may be appropriate. Antiepileptic medications have not proven helpful. Metformin has been used for weight loss in children but is not approved by FDA and has only small effect on weight with unclear clinical significance. Orlistat is approved for children age 12 and older; however, the benefits are limited to 2 to 3 kg of weight loss. Side effects are often intolerable and include loose, oily stools and stool urgency (just mention the phrase “fecal incontinence” to a teenager and see how far you get). Experts agree that orlistat is only appropriate for adolescents with comorbidities caused by obesity. Obesity (“bariatric”)surgery (especially Roux-en-Y and gastric sleeve) is being performed more often on adolescents and is effective at reversing metabolic changes (insulin resistance, hypertryglyceridemia, etc.). It also improves sleep apnea and depression and improves quality of life.

Question 32

Her BMI is now at the 97th percentile, having jumped from the 86th percentile last year. What additional workup should be considered? A. Fasting plasma glucose level or hemoglobin A1c B. Fasting lipids C. Renal function testing with BUN and creatinine D. Liver function testing with ALT E. All of the above

Answer 32

E. All of the above Expert opinion suggests that once a child reaches a BMI at the 85th to 94th percentiles, a lipid panel and a fasting glucose or A1c should be obtained to evaluate for hyperlipidemia and early onset type 2 diabetes. When the BMI reaches the 95th percentile, renal function and blood pressure should be monitored, and liver function should be checked (for fatty liver). Fatty liver disease is possible at an early age and is reversible if weight loss can be achieved. Close attention to family history is essential. If family members are obese or have obesity-related comorbidities, early intervention and evaluation are even more crucial. For females who have started menses, it is important to assess for any changes in menstrual patterns.

Question 33

Which of the following is NOT a recommended early childhood intervention to prevent and/or treat obesity? A. Encouraging breastfeeding B. Decreasing screen time of electronic devices C. Planning fewer family meals D. Restricting calories from sweets and fast foods E. Improving efforts for exercise and outdoor activity

Answer 33

C. Planning fewer family meals Helping with food preparation and sitting down as a family for meals can lead to consumption of more nutritious and lower caloric dense foods. Breastfeeding can lead to protection against obesity even into the teenage years. Formal recommendations suggest limiting TV, tablet, phone, computer use, and video games to less than 2 hours per day with minimal screen time for children under age 2. Fast food, sweets, and desserts need to be limited to small servings or few servings per week. Finally, at least 60 minutes of exercise should be encouraged every day—doing a variety of activities will keep children more engaged and interested.

Question 34

During the examination of the patient, you notice acne, some coarse facial hair, and dark skin pigmentation around the base of her neck. What is another finding you may expect to see with further questions and tests? A. Normal menses B. Low free testosterone level C. Low DHEA sulfate (DHEA-S) D. Hypoglycemia E. Abnormal hypothalamic–pituitary axis hormones

Answer 34

E. Abnormal hypothalamic–pituitary axis hormones While the earliest clinical manifestation is irregular menses, she is showing other signs of possible polycystic ovarian syndrome (PCOS). This can be associated with elevated prolactin, low TSH, and a marked elevation of FSH relative to luteinizing hormone (LH). PCOS can be associated with early menarche, dysmenorrhea, and amenorrhea. A pregnancy test should be done in any case of amenorrhea. PCOS is also associated with elevations of testosterone, DHEA-S, and androstenedione. If there are other significant physical examination findings such as elevated blood pressure, purple striae, and a “buffalo hump,” consider testing for Cushing syndrome. See chapter 15 for more on PCOS.

Question 35

A 13-year-old Native American female has a body mass index (BMI) at the 90th percentile for age. The primary care pediatric nurse practitioner notes the presence of a hyperpigmented velvet-like rash in skin folds. The child denies polydipsia, polyphagia, and polyuria. The nurse practitioner will take what action? A. Counsel the child to lose weight to prevent type 2 diabetes B. Diagnose type 2 diabetes if the child has a random glucose of 180 mg/dL C. Order a fasting blood sample for a metabolic screen for type 2 diabetes D. Refer the child to a pediatric endocrinologist

Answer 35

C. Order a fasting blood sample for a metabolic screen for type 2 diabetes This child has three risk factors for type 2 diabetes: Native American ethnicity, overweight, and acanthosis nigricans. The PNP should perform metabolic screening on a fasting blood sample to diagnose this. Lifestyle changes may be necessary to control the disease if diagnosed, but this child may already have the disease, and management options aren’t clear until the diagnosis is made. Diagnosis is based on a random glucose >200 mg/dL. It is not necessary to refer this child until a diagnosis is made.

Question 36

A 6-year-old child has a systolic blood pressure between the 95th and 99th percentile for age, sex, and height, and a diastolic blood pressure between the 90th and the 95th percentile on three separate clinic visits. This child’s blood pressure is placed in which classification? A. Normotensive B. Pre-hypertensive C. Stage 1 hypertensive D. Stage 2 hypertensive

Answer 36

C. Stage 1 hypertensive Stage 1 hypertensive pressure ranges from the 95th percentile or from 120/80 mm Hg to 5 mm Hg above the 99th percentile for age, sex, and height for either systolic or diastolic pressure. Normotensive pressure is below the 90th percentile. Pre-hypertensive pressure is between the 90th and 95th percentiles. Stage 2 hypertensive pressure is greater than the 99th percentile.

Question 37

A 12-year-old child whose weight and body mass index (BMI) are in the 75th percentile has a diastolic blood pressure that is between the 95th and 99th percentiles for age, sex, and height on three separate occasions. Which test will be prescribed for this child initially? A. Complete blood count B. Erythrocyte sedimentation rate C. Renal function D. Urinalysis and electrolytes

Answer 37

C. Renal function Since the majority of children with stage 1 or 2 hypertension have renal or renovascular causes for elevated BP, renal function and plasma renin tests should be performed. Children under 10 years of age with stage 2 hypertension should have more aggressive laboratory evaluation, including CBC, ESR, UA, and electrolytes.

Question 38

A 12-year-old child whose body mass index (BMI) is greater than the 95th percentile has a blood pressure at the 98th percentile for age, sex, and height. After lifestyle changes that include diet and exercise, the child’s BMI drops to the 90th percentile, but the blood pressure remains the same. What is the primary care pediatric nurse practitioner’s next step in treating this child? A. Continued close monitoring of blood pressure B. Ordering an echocardiogram C. Prescribing an ACE inhibitor medication D. Referral to a nephrologist or cardiologist

Answer 38

D. Referral to a nephrologist or cardiologist Children who have persistent BP elevation after lifestyle changes are made should be referred to a nephrologist or cardiologist who has experience using antihypertensive agents in children. The specialist orders necessary tests and medications, not the primary care provider.

Question 39

Liver function tests should be monitored routinely every 4 months in the client on maintenance therapy with all hypolipidemic drugs EXCEPT: Select one: a. Bile acid sequestrants b. Hydroxymethylglutaryl-coenzyme A reductase inhibitors c. Nicotinic acid d. Fibric acid derivatives

Answer 39

a. Bile acid sequestrants

Question 40

A 67-year-old patient with newly diagnosed hypertension is a smoker with diabetes mellitus. Which of the following medications has the potential to cause the development of bronchial asthma and inhibit gluconeogenesis? a. ACE inhibitors b. Beta-blockers c. Calcium channel blockers d. Diuretics

Answer 40

b. Beta-blockers

Question 41

A provider wants to run initial testing to determine target organ damage and other risk factors in a patient diagnosed with hypertension. Which tests should be included? a. Chest xray, electrocardiogram, urinalysis, complete blood count, chemistry profile, lipid profile, and TSH level. b. Renal arteriogram c. Plasma renin activity and 24-hour urinary sodium d. Echocardiogram

Answer 41

a. Chest xray, electrocardiogram, urinalysis, complete blood count, chemistry profile, lipid profile, and TSH level.

Question 42

Many patients need two or more agents to help control hypertension. If a patient has a SBP >160 and/or DBP > 100, and has a PMH relevant for uncontrolled essential HTN, DM, what is the best initial combination therapy? a. Lasix and a beta-blocker b. Thiazide diuretic and an ACE inhibitor c. Nitrate and a beta blocker d. Thiazide and a calcium channel blocker

Answer 42

b. Thiazide diuretic and an ACE inhibitor

Question 43

Which antihypertensive medications are the most effective in treating hypertension in African Americans and older adults? a. Diuretics b. ACE inhibitors c. Beta blockers d. Alpha-adrenergic blockers

Answer 43

a. Diuretics

Question 44

What are the recommendations when treating high triglycerides? a. Aggressively treat with fenofibrates b. Treatment should be with combination therapy with a statin and fenofibrate c. Focus on lifestyle changes as initial therapy d. Use a bile acid sequestrant.

Answer 44

c. Focus on lifestyle changes as initial therapy

Question 45

Normal BP

Answer 45

<120/80

Question 46

Elevated BP

Answer 46

SBP 120- 129 AND DBP < 80 reassess BP in 3- 6 mo

Question 47

Stage 1 HTN

Answer 47

SBP 130- 139 OR DBP 80-89

Question 48

Stage 2 HTN

Answer 48

SBP > 140 OR DBP >/= 90

Question 49

HTN dx

Answer 49

Average of TWO or more properly measured, seated BP recordings on TWO separate occasions

Question 50

Common factors associated with elevated BP

Answer 50

-Pain -Excess dietary intake of sodium (even for patients who don’t add salt to their food—recall that many canned/processed foods are high in sodium -Alcohol consumption (especially when the use is chronic or heavy) -Tobacco use -Stress -Anxiety (such as with white coat hypertension) -Use of decongestants (in many cough/cold preparations which can be obtained over the counter, including pseudoephedrine, phenylephrine, and oxymetazoline) -Some herbal supplements -Many commonly used drugs (such as NSAIDs, sympathomimetics, oral contraceptive pills, illicit drugs, etc) -Obesity -Obstructive sleep apnea -Black licorice (the ”real stuff” from the root of Glycyrrhiza glabra which contains glycyrrhizinic and glycyrrhetinic acid) can also cause an elevation in blood pressure (and hypokalemia) by indirectly antagonizing the aldosterone receptors in the kidney

Question 51

HTN non-pharmacological management

Answer 51

Lifestyle modifications: - diet (low sodium & DASH diet - high in fruits, veggies, low-fat dairy, reduced saturated and total fat) sodium intake < 2400mg/day - exercise: moderate-vigorous activity 3-4 days a week ~ 40 mins - weight loss - moderate alcohol consumption (men 2 drinks/day women 1 drink/day) - smoking cessation - control BG & lipids

Question 52

Initial workup for HTN dx

Answer 52

``` fasting blood glucose CBC lipid profile serum Cr w/ eGFR serum NA, K, Ca TSH US ECG ``` optional: echocardiogram, uric acid, urinary ACR ratio

Question 53

ADA recommendations for DM screening

Answer 53

Adults of any age who are overweight/obese (BMI > 25; > 23 Asians) AND another RF: - First-degree relative with diabetes - High-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander) - History of CVD - Hypertension (>140/90 mmHg or on therapy for hypertension) - HDL cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglyceride level >250 mg/dL (2.82 mmol/L) - Women with polycystic ovary syndrome - Physical inactivity - Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans) Patients with prediabetes (A1C >5.7% [39 mmol/mol], IGT, or IFG) should be tested yearly. Women who were diagnosed with GDM should have lifelong testing at least every 3 years. For all other patients, testing should begin at age 35 years. If results are normal, testing should be repeated at a minimum of 3-year intervals, with consideration of more frequent testing depending on initial results and risk status. People with HIV

Question 54

ADA recommendations for DM screening in children

Answer 54

Risk-based screening for type 2 diabetes or prediabetes in asymptomatic children and adolescents in a clinical setting: Screening should be considered in youth who have overweight (>85th percentile) or obesity (>95th percentile) AND who have one or more additional risk factors: - Maternal history of diabetes or GDM during the child’s gestation - Family history of type 2 diabetes in first- or second-degree relative - Race/ethnicity (Native American, African American, Latino, Asian American, Pacific Islander) - Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, polycystic ovary syndrome, or small-for gestational-age birth weight)

Question 55

HTN management guidelines | stage 1 HTN with ASCVD risk < 10%

Answer 55

non-pharmacological tx | lifestyle modifications with a repeat BP in 3- 6 months

Question 56

HTN management guidelines stage 1 HTN AND ASCVD risk >/= 10%

Answer 56

COMBINATION lifestyle modification and 1-drug tx follow-up BP in a month

Question 57

HTN management guidelines stage 2

Answer 57

lifestyle modifications and 2- drug tx from different classes Recheck BP in a month

Question 58

Management of BP > 180/ 110

Answer 58

evaluation followed by prompt antihypertensive drug tx | do NOT wait for second BP to dx, start tx

Question 59

Follow-up adults with well controlled HTN

Answer 59

annually

Question 60

JNC 8 target BP goal after tx

Answer 60

No diabetes or CKD: Age < 60 BP goal < 140/90 Age > 60 BP goal < 150/90 DM or CKD: All ages < 140/90

Question 61

AHA target BP goal

Answer 61

< 130/80

Question 62

HTN med nonblack

Answer 62

thiazide ACEI ARB CCB alone or in combo

Question 63

HTN med black

Answer 63

thiazide or CCB alone or in combo

Question 64

HTN med diabetes

Answer 64

same as normal management, depends on race

Question 65

HTN med CKD

Answer 65

ACEI or ARB alone or in combo w/ another class

Question 66

After tx, BP not at target goal, what do you do?

Answer 66

reinforce lifestyle and adherence (A) Start one drug, titrate to max dose, then add second drug (B) Start one drug, then add a second drug before achieving max dose of 1st (C) begin 2 drugs at same time, as separate pills or combo Initial combo tx recommended if BP > 20/10 above goal

Question 67

HTN meds contraindicated in pregnancy

Answer 67

ACEI ARBs avoid if chance pt can get pregnant

Question 68

HTN & CHF meds

Answer 68

ACEI/ARB BB thiazides spironolactone

Question 69

HTN & post MI/CAD meds

Answer 69

ACEI/ARB BB aldostosterone antagonist

Question 70

HTN & high CV risk meds

Answer 70

thiazides BB ACEI CCB

Question 71

HTN & DM meds

Answer 71

thiazides ACEI ARB CCB

Question 72

HTN & CKD meds

Answer 72

ACEI/ARB

Question 73

HTN & recurrent stroke prevention meds

Answer 73

ACEI | diuretics

Question 74

HTN & BPH meds

Answer 74

alpha blocker

Question 75

HTN & pregnancy meds

Answer 75

labetolol (1st line) | nifedipine, methyldopa

Question 76

diuretics

Answer 76

HCTZ, chlorthalidone, indapamide spironolactone furosemide, torsemmide monitor for hypokalemia most effective w/ ACEI loops may be needed when GFR < 40

Question 77

ACEI

Answer 77

"-pril" SE cough, angioedema, hyperkalemia

Question 78

ARBs

Answer 78

"-sartan" hyperkalemia Losartan lowers uric acid

Question 79

Beta-blockers

Answer 79

"lol" NOT 1st line- reserve post-MI/CHF cause fatigue, decrease HR adversely affect glucose , mask hypoglycemia

Question 80

Calcium channel blockers

Answer 80

dihydropyridines: "pines" can combine w/ BB non-dihydropyridines: diltiazem, verapamil reduce HR and proteinuria cause edema

Question 81

Benazepril should be DC immediately if: A. dry cough develops B. pregnancy occurs C. K levels decrease

Answer 81

B. pregnancy occurs Benazepril is an ACEI and is CONTRAINDICATED in pregnancy r/t teratogenic effects on renal system of developing fetus Dry cough is aggravating SE but DC is elective Associated with elevated K levels, not decreased

Question 82

Characteristic of ACEI induced cough: A. non-productive B. worse at night C. usually beings within 2 weeks of tx D. more common in men

Answer 82

A. non productive cough is typically dry and non productive. Bradykinin is partly degraded by ACE, degradation and conversions of angiotensin 1 to angiotensin II by ACE occurs in lung. when degradation is impaired, bradykinin can accumulate and cough can ensure can happen at any time of day, can start at any time within 2 weeks or 1 year later

Question 83

A patient taking an ACEI should avoid: A. K supplements B. protein rich meals (h/o gout) C. grapefruit juice

Answer 83

A. K supplements ACEI can cause HYPERKALEMIA because it spares K in renin angiotensin aldosterone system. If K taken in supplements, risk of hyperkalemia is increased

Question 84

Which patient could be expected to have the HIGHEST SBP? A. 21 y.o. M B. 50 y.o. perimenopausal F C. 35 y.o. T2DM D. 75 y.o. M

Answer 84

D. 75 y.o. M Greatest incidence of HTN is in older adults r/t changes in intima of vessels as aging and calcium deposition occur. Males of any age are more likely to be hypertensive than F in same age. African Americans have highest incidence in general population.

Question 85

A 50 y.o. pt with HTN has taken HCTZ 25mg daily for the past 4 weeks. Her BP has decreased from 155/95 to 145/90. How should the NP proceed? A. Wait another 4 weeks before making a dosing change B. Increase HCTZ to 50mg daily C. Add a drug from another class to the daily 25mg HCTZ D. Stop the HCTZ and start a drug from a different class

Answer 85

C. Add a drug from another class to the daily 25mg HCTZ ``` The recommended target BP is < 140/90. The current plan has not allowed this patient to meet this goal, so it is not acceptable to continue this current dose. Increasing the HCTZ to 50mg/daily will NOT result in a decrease in BP, only an increase in K loss. Adding a drug from another med class is a good choice because the combined effects of antihypertensive medication nearly always produce a decrease in BP and both drugs can be maintained in low doses to minimize side effects. Thiazides are most effective in combo with ACEI ```

Question 86

Conditions suggestive of possible secondary HTN

Answer 86

drug-resistant induced HTN abrupt onset of HTN onset of HTN at age < 30 exacerbation of previously controlled HTN accelerated/malignant HTN onset of diastolic HTN in older adults (>65) unprovoked or excessive hypokalemia

Question 87

Causes of secondary HTN

Answer 87

 Apnea (OSA)  Aldosteronism (Primary hyperaldosteronism)  Bruits (Renovascular disease such as renal artery stenosis or fibromuscular dysplasia)  Bad parenchymal disease (Chronic kidney disease)  Catecholamines (Pheochromocytoma, other catecholamine release situations, decongestants, herbal preparations)  Coarctation of the aorta  Cushing’s syndrome and other excess glucocorticoid states  Drug induced or related (see Table 2 of the Onusko article  Diet (excess of sodium, alcohol, black licorice)  Erythropoietin excess (exogenous or secondary to COPD/polycythemia)  Endocrine disorders (not already listed): hypothyroidism, hyperthyroidism, hyperparathyroidism, pregnancy-induced hypertension, pheochromocytoma, acromegaly

Question 88

Benefits of HTN lifestyle management

Answer 88

DASH diet reduces BP by 8-14 mm Hg (similar to 1 drug tx) weight loss reduces BP by 5- 20 mm Hg per 10 kg of weight loss Na restriction reduces BP by 2 to 8 mm Hg Physical activity reduces BP by 4- 9 mm Hg moderation in alcohol consumption reduces BP by 2- 4 mm Hg

Question 89

When should HTN patients follow up in two weeks?

Answer 89

When started on ACEI/ARB or aoldosterone antagonists to check K, Cr, and evaluate BP control

Question 90

Which of the following hypertension medications should not be used in pregnant women? A. Calcium channel blockers B. Thiazide diuretics C. Angiotensin II receptor blockers (ARBs) and angiotensin-converting enzyme (ACE) inhibitors D. Beta blockers

Answer 90

C. Angiotensin II receptor blockers (ARBs) and angiotensin-converting enzyme (ACE) inhibitors Angiotensin II receptor blockers (ARBs) and angiotensin-converting enzyme (ACE) inhibitors are designated as pregnancy category “X” and may cause congenital abnormalities, especially in the second and third trimester. Calcium channel blockers such as nifedipine and beta blockers such as labetalol are preferred for the treatment of hypertension in pregnant women. Diuretics, such as thiazide diuretics, may be used with caution in pregnant women but may increase the risk of maternal volume loss.

Question 91

A 52-year-old man presents to your office for a health maintenance exam, and initial vital signs show a blood pressure of 154/94 mm Hg. Previous blood pressure measurements were normal. What is the next step in management? a. Start an antihypertensive medication b. Repeat the blood pressure measurement c. Look for causes of secondary hypertension d. Perform a urine drug screen

Answer 91

b. Repeat the blood pressure measurement If the initial blood pressure measurement is elevated, it should be repeated. The diagnosis of hypertension is based on the average of two or more properly measured blood pressure values over two or more visits. It would be incorrect to start an antihypertensive medication after the first measurement of an elevated blood pressure. While it is important to consider secondary causes of hypertension, the diagnosis of hypertension must first be made by repeating the blood pressure measurement and recording multiple instances of elevated blood pressure. While a urine drug screen may be helpful in the search for substances that may cause elevated blood pressure (such as cocaine and methamphetamine), the elevated blood pressure measurement should first be repeated before any other workup is undertaken.

Question 92

Which of the following statements is correct regarding blood pressure evaluation? a. The patient should be lying quietly on the exam table for 5 minutes prior to obtaining a blood pressure measurement. b. Arm should be below heart level during blood pressure measurement. c. The bladder of the blood pressure cuff should encircle 80% of the forearm. d. Hypertension can be diagnosed by the average of two elevated blood pressure readings on a single occasion.

Answer 92

c. The bladder of the blood pressure cuff should encircle 80% of the forearm. It is essential to use the correct blood pressure cuff size in the assessment of blood pressure, as cuffs that are too large or small will give incorrect values. The bladder of the blood pressure cuff should encircle 80% of the forearm. The patient should be sitting upright quietly for 5 minutes prior to obtaining a blood pressure measurement. The arm should be supported and held at heart level. Use an average of more than two readings on two separate occasions to assess an individual’s blood pressure.

Question 93

Which of the following antihypertensive medications should be avoided in patients with gout? a. Losartan b. Hydrocholorthiazide c. Nifedipine d. Atenolol

Answer 93

b. Hydrocholorthiazide Thiazide diuretics such as hydrochlorothiazide and loop diuretics such as furosemide may increase blood uric acid levels, thereby increasing the risk of gouty flares. Calcium channel blockers (CCBs) and the angiotensin II receptor blocker (ARB) losartan may decrease the incidence of gouty flares. Beta blockers such as atenolol are not associated with increased risk of gout flares.

Question 94

Which of the following antihypertensive medications should be avoided in patients with poorly controlled asthma? a. Losartan b. Hydrochlorothiazide c. Nifedipine d. Atenolol

Answer 94

d. Atenolol Beta blockers such as atenolol may cause bronchoconstriction in patients with asthma. Diuretics such as hydrochlorothiazide, calcium channel blockers such as nifedipine, and angiotensin II receptor blockers such as losartan can be used to treat hypertension in patients with asthma.

Question 95

Which of the following antihypertensive medications should not be used as a first-line treatment for a person with essential hypertension and no other medical conditions? a. ACE Inhibitor b. Beta Blocker c. Calcium channel blocker d. Diuretic (thiazide diuretic)

Answer 95

b. Beta Blocker According to the 2017 American College of Cardiology (ACC) guidelines and the 2014 Joint National Committee (JNC) guidelines, thiazide diuretics or calcium channel blockers are generally considered first-line options for therapy in all persons with hypertension. ACE inhibitors and angiotensin receptor blockers (ARBs) are also recommended as options in non- black patients. This is a departure from prior recommendations when ACE inhibitors and ARBs were routinely recommended as first-line therapy for Caucasian patients. Beta blockers (unless there are other factors such as a history of coronary artery disease or cardiac arrhythmias) are not recommended for routine first-line therapy of essential hypertension.

Question 96

Which of the following medications should be discontinued in a woman with essential hypertension who is trying to get pregnant? a. Methyldopa b. Labetalol c. Nifedipine d. Losartan

Answer 96

d. Losartan ACE inhibitors and ARBs are a pregnancy class D (known to cause fetal abnormalities). Losartan, an ARB, should be discontinued in a woman who is trying to get pregnant. Methyldopa (antiadrenergic), labetalol (beta blocker), and nifedipine (calcium channel blocker) are preferred medications for chronic hypertension in pregnancy. These medications are characterized as pregnancy class C (risk cannot be ruled out) although they have no known association with congenital abnormalities but may cause neonatal hypotension.

Question 97

ACC/AHA guidelines (2018), who are the individuals most likely to benefit from starting on a statin therapy?

Answer 97

Statin therapy is recommended for:  Patients with clinical atherosclerotic cardiovascular disease (ASCVD) - either a high- intensity statin, or the maximally tolerated dose of a statin  Patients with severe primary hypercholsterolmia (LDL > 190 mg/dL) regardless of their 10-year ASCVD risk – high dose statin  Patients age 40-75 years with diabetes and LDL > 70 mg/dL – start moderate-intensity statin (no (need to calculate the 10-year ASCVD risk) Statin therapy should be considered in:  Patients age 40-75 years without diabetes and LDL > 70 mg/dL and a 10-yeaer ASCVD risk ≥7.5% - consider treatment with a moderate-intensity statin. Other agents?  Patients at very high-risk for ASCVD with a LDL > 70 mg/dL – consider addition of ezetimibe if LDL > 100 mg/dL

Question 98

According to the 2018 ACC/AHA lipid guidelines, are there any specific LDL treatment goals?

Answer 98

No. Rather than treating to a specific LDL cholesterol (e.g., <70 mg/dL) and/or non-HDL cholesterol treatment target, the appropriate intensity of statin therapy is targeted to reduce the ASCVD risk in patients who are likely to benefit. In general, high-intensity statin therapy is designed to lower LDL by ≥50%, moderate-intensity statin therapy by 30-49%, and low-intensity statin therapy by <30%.

Question 99

Statin cautions/contradinications

Answer 99

Contraindication - pregnancy, cholestatic liver dx Caution - active liver dx, transaminitis

Question 100

Side effects statins

Answer 100

myopathy | elevated liver transaminases

Question 101

Monitoring guidelines for statins

Answer 101

Cr, CK, and LFTs at baseline monitor LFTs as clinically indicated, not routine. Prudent in pts w. symptoms of liver dx or risk of worsening liver dx

Question 102

A 45-year-old woman with a BMI of 33 kg/m2 comes to primary care clinic for her annual physical exam. She does not smoke and does not have diabetes. She has no family history of early CAD. She is not fasting today, but cannot easily return for a fasting lipid profile. Her TC is 148 mg/dL, TG is 523 mg/dL, HDL is 47 mg/dL, and LDL was not able to be calculated because TG is greater than 400 mg/dL. The direct LDL was 53 mg/dL. Because of the patient’s hypertriglyceridemia and obesity, you advise her to adopt a low-fat, low cholesterol diet, increase her physical activity, and follow up for a fasting lipid profile in 6 months. After rigorous diet and exercise efforts, she returns to clinic. Her BMI is 28 kg/m2. Repeat labs are: TC = 144 mg/dL, TG = 267 mg/dL, HDL = 40 mg/dL and LDL = 51 mg/dL. Does she warrant drug treatment for a dyslipidemia?

Answer 102

No. The 2018 ACC/AHA guidelines do not specifically address treating elevations in the triglycerides. It is suggested that elevated triglycerides (greater than 500 mg/dL) prompt consideration of other secondary causes of hyperlipidemia, including diet, certain drugs, nephrotic syndrome, chronic renal failure, lipodystrophies, poorly controlled diabetes, hypothyroidism, obesity, and pregnancy.1 She has limited other cardiovascular risk factors identified. She could likely continue to benefit from a high fiber (10 to 25 g/day), low cholesterol (less than 200 mg/day) diet, with less than 7% of calories from saturated fat. It could also be prudent to advise her to increase her physical activity and work on weight reduction.

Question 103

Screening for dyslipidemia in children

Answer 103

universal screening for dyslipidemia should occur once between ages 9 and 11 years and once between ages 17 and 21 targeted screening in children between the ages of 2 and 8 years of age Children (ages 2-8) should also have a fasting lipid profile checked twice (with averaged results used to make treatment decisions):  Children with a parent, grandparent, aunt/uncle, or sibling with myocardial infarction (MI), angina, stroke, or coronary artery bypass graft (CABG)/stent/angioplasty when younger than 55 years in males and 65 years in females  Any child with a parent who has a TC greater than 240 mg/dL or known dyslipidemia  Any child with diabetes, hypertension, BMI greater than 95th percentile or who smokes cigarettes  Any child who has one of the following moderate- or high-risk medical conditions: o High Risk  Type 1 or type 2 diabetes mellitus  Chronic kidney disease, end-stage renal disease (ESRD), history of renal transplant  History of orthotopic heart transplant  Kawasaki disease with current aneurysms o Moderate Risk  Kawasaki disease with regressed coronary aneurysms  Chronic inflammatory disease (systemic lupus erythematosus, juvenile rheumatoid arthritis)  HIV infection  Nephrotic syndrome  Note: The USPSTF gives lipid screening in children and adolescents an “I” recommendation (“I” = insufficient evidence) and were last updated in August, 2016.8 This illustrates some of the controversy that has surrounded universal screening in children. Regardless, both Bright Futures and the 2018 ACC/AHA lipid guidelines recommend universal screening between ages 9-11 years and 17-21 years of age.1

Question 104

Abnormal lipid profile management in children < 10 y.o.

Answer 104

weight loss increased physical activity nutritonal counseling -reduced-fat dairy products of > 1 y.o. evaluation and treatment of dyslipidemias in children has not been adequately studied nor shown to have a similar benefit that was demonstrated in adults. Subsequently, it has been noted by the USPSTF that the adverse effects of both lipid-lowering drugs and low-fat diets have not been adequately evaluated in children. In addition, there have been concerns about increased anxiety in screened children and adolescents.

Question 105

Abnormal lipid profile management in children >/= 10 y.o.

Answer 105

Elevated LDL cholesterol levels, a cholesterol lowering medication “should be considered.”

Question 106

Which of the following lab values are the most likely to be affected by eating within an hour of lab draw? a. Direct low-density lipoproteins (LDL) b. Total LDL c. Triglycerides d. High-density lipoprotein (HDL)

Answer 106

c. Triglycerides Triglyceride values are the most likely to be affected by eating within an hour of blood being drawn. The total LDL and HDL values are usually not affected by eating. While the calculated LDL measure (Total Cholesterol - HDL – [TG / 5]) is affected by eating (as it uses the triglyceride measurement in the calculation), the direct LDL value is not affected by eating.

Question 107

What is the mechanism of action of ezetimibe? a. Inhibits 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase b. Inhibits cholesterol absorption at the brush border of the small intestine c. Activates a nuclear transcription factor that regulates lipid metabolism d. Acts as a resin to bind cholesterol and prevent absorption from the digestive tract

Answer 107

b. Inhibits cholesterol absorption at the brush border of the small intestine Ezetimibe blocks absorption of cholesterol in the brush border of the small intestine. Statins such as atorvastatin and pravastatin are HMG-CoA reductase inhibitors, thereby limiting the rate of hepatic cholesterol synthesis and leading to increased peripheral LDL receptor expression and LDL uptake from the blood. Fibrates such as gemfibrozil activate peroxisome proliferator- activated receptor alpha (PPAR-alpha), a nuclear transcription factor that regulates lipid metabolism, and are used in the treatment of severe hypertriglyceridemia. Bile acid sequestrants, such as cholestyramine and colestipol, are resins that bind cholesterol in the gastrointestinal tract and increase cholesterol excretion in the stool.

Question 108

According to the 2018 American College of Cardiology / American Heart Association (ACC/AHA) guidelines, which of the following patients should receive statin therapy? a. A patient with a 15% ten-year risk of development of atherosclerotic cardiovascular disease b. A patient with type 1 diabetes mellitus and an LDL cholesterol of 90 mg/dL c. A patient with LDL cholesterol greater than or equal to 200 mg/dL d. All of the above

Answer 108

d. All of the above According to experimental data with high-quality evidence, the following four groups of individuals have been shown to benefit from treatment with HMG-CoA (3-hydroxy-3-methyl- glutaryl-coenzyme A) reductase inhibitors (statins): 1) persons who already have atherosclerotic cardiovascular disease (ASCVD); 2) those who are likely to have greater than or equal to 7.5% risk of development of ASCVD within the next decade; 3) persons with diabetes mellitus (type 1 or type 2) who have an LDL cholesterol greater than or equal to 70 mg/dL and 4) persons with an LDL cholesterol greater than or equal to 190 mg/dL.

Question 109

HLD RF

Answer 109

``` increasing age male genetic disorders of lipid metabolism fam hx of premature CAD cigarette smoking obesity HTN HLD with elevated LDL & low HDL cholesterol DM ```

Question 110

HLD screening guidelines

Answer 110

``` asymptomatic adults (40- 79): perform 10-year ASCVD risk score ``` high-risk patients: primary elevation LDL-C > 190 T1 or T2DM w/ LDL-C 70- 189 without clinical ASCVD LDL 70-189 and estimated 10-year ASCVD risk score > 7.5% Adults 40-79 w/ DM: measure fasting lipids at least annually every 2 years for adults with low-risk lipid values (LDL-C < 100, HDL-C > 50, TG < 150)

Question 111

high dose statin tx in patients with

Answer 111

clinical ASCVD | severe primary hypercholesterolemia LDL > 190 regardless of 10-y ASCVD risk

Question 112

Moderate dose statin tx in patients

Answer 112

ages 40-75 y.o. WITH DM and LDL > 70 | no need to calculate 10-y ASCVD risk

Question 113

total cholesterol level

Answer 113

< 200 desirable 200-239 borderline high >/= 240 high

Question 114

LDL-C level

Answer 114

< 100 optimal 100-129 above optimal 130-159 borderline high 160- 189 high >/= 190 very high

Question 115

HDL-C level

Answer 115

> 40 M > 50 F

Question 116

A patient taking atorvastatin for newly diagnosed dyslipidemia complains of fatigue, weakness, and muscle aches in his lower back, arms, and legs for the past 3 days. It has not improved with rest. How should this be evaluated? A. Stop the atorvastatin immediately B. Check liver enzymes first C. Order a CPK level D. Ask about nighttime muscle cramps

Answer 116

A. Stop atorvastatin immediately The complaints highly suggest rhabdomyolysis. The atorvastatin should be stopped immediately and a CPK should be ordered. Liver enzymes would not assess for the etiology of myalgias. They asses tolerance to statins in liver. Nighttime muscle cramps are not usually associated with statin use. Myalgias are common but not typically associated with elevated CPK. Rhabdo is a rare side effect of statins.

Question 117

Metabolic Syndrome defined as

Answer 117

Presence of any THREE of the following five: (1) abdominal obesity, waist circumference >/= 102 cm (40 in) in M and >/= 88cm (35 in) F (2) serum triglycerides >/= 150 or drug tx for elevated triglycerides (3) serum HDL-C < 40 in M and < 50 in F or drug tx for low HDL-C (4) BP >/= 130/85 or drug tx for HTN (5) fasting plasma glucose >/= 100 or drug tx for elevated blood glucose

Question 118

HTN: end organ damage

Answer 118

heart: MI, LVH, HF, atherosclerosis, CAD, dissecting AA Brain: stroke, TIA, CVA, aneurysm, hemorrhage Kidneys: kidney dx/ ESRD (increase or decrease GFR) Eyes: vision loss, retinal exudates, hemorrhages, retinopathy lower extremities: atherosclerosis, intermittent claudication sexual dysfunction: ED, low libido F

Question 119

Pedi obesity screening

Answer 119

USPSTF: children >/= 6 y.o. screen for obesity and offer or refer to comprehensive, intensive behavioral interventions to promote improvement in weight status ALL children screened screening tests: BMI age/sex specific BMI >/= 95th percentile

Question 120

RF child obesity

Answer 120

``` parental obesity poor nutrition low levels physical activity inadequate sleep sedentary behavior low family income ```

Question 121

overweight

Answer 121

BMI > 25

Question 122

Obese

Answer 122

BMI > 30

Question 123

child obesity

Answer 123

>/= 95th percentile

Question 124

child overweight

Answer 124

85th-95th percentile

Question 125

child dx w/ obesity | Screen for comorbidities for those BMI > 85th percentile for age and gender

Answer 125

Prediabetes and T2DM Dyslipidemia and fasting lipid panel Nonalcoholic steatohepatitis with liver enzyme alanine aminotransferase (ALT) OSA - hx snoring, daytime somnolence - refer pedi pulmonology PCOS - free and total testosterone level Pre- HTN and HTN w/ BP measurements Psychological issues - hx low self-esteem, behavior problems, depression

Question 126

HTN < 6 y.o.

Answer 126

Secondary HTN more common in children < 6 y.o. - Renovascular or parenchymal renal dx - Coarctation of aorta, endocrine disorders, genetic disorders (Williams syndrome, neurofibromatosis and tuberous sclerosis, drugs, CNS tumors)

Question 127

Dx HTN children

Answer 127

``` Stage I (>/= 130/80 to 139/89 ) & II HTN (>/= 140/90 ) Focus on secondary causes, comorbidities, and target end organ damage Labs → renal function tests and plasma renin levels ```

Question 128

Dx Children < 10 y.o. w/ Stage II HTN

Answer 128

Aggressive lab evaluation compared to older children | Labs → CBC, ESR, CRP, UA & culture, electrolytes, BUN, Cr, plasma renin levels

Question 129

HTN Management children

Answer 129

BPs annually starting at age 3 Elevated BP, 2 follow-up BPs within 1- 2 months Primary HTN → diet, exercise, weight management Avoid caffeine, alcohol, smoking, illicit drugs If persists, referral to nephrologist or cardiologist for antihypertenive agents in children

Question 130

Dx HLD

Answer 130

``` Fasting lipid panel every 5 years in adults older than 20 y.o. Total cholesterol < 200 LDL-C < 100 HDL-C > 60 Triglycerides < 150 ``` Estimate 10-year ASCVD risk every 4- 6 years

Question 131

labs after initiation of lipid-lowering agents:

Answer 131

After initiation of lipid-lowering agents: Second fasting lipid panel in 4- 12 weeks Then every 3- 12 months LFTs BEFORE statins initiated Do not repeat unless S/S of liver dx or adverse reactions

Question 132

Young Adults HLD management

Answer 132

>/= 19 y.o. W. high LDL-C > 190 have high lifetime risk of CV events Tx w/ moderate to high intensity statins Screen family Lifestyle modification/risks Excessive alcohol intake, diabetes, diet, exercise, weight control, drug, alcohol, tobacco use

Question 133

High-dose statin =

Answer 133

atorvastatin 40–80 mg or rosuvastatin 20–40 mg

Question 134

Low-to-moderate dose statin =

Answer 134

atorvastatin 10–20 mg QD pravastatin 40–80 mg BID rosuvastatin 5–10 mg QD

Question 135

Pedi management HLD

Answer 135

Lifestyle changes Diet → increase fiber, consult w. Pedi RD Medications Children >/= 8 y.o after 6- 12 months of diet and lifestyle changes who continue to have: LDL > 190 LDL between 160 and 190 AND positive fam hx of premature CHD or two RF: Smoking, HTN, HDL level < 35, obesity, DM, physical inactivity, male sex, renal dx, lupus, RA, HIV, nephrotic syndrome, Kawasaki dx Statins Refer to specialized pedi lipid center