Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 48-year-old woman is evaluated during a follow-up visit. She has a 5-year history of type 2 diabetes mellitus. She has no other significant medical history. Medications are atorvastatin, metformin, and a multivitamin. She works as a mail carrier and has a walking route that takes 3 hours each day. She consumes a diet high in fruits and vegetables and does not smoke.

On physical examination, the patient is afebrile, blood pressure is 128/80 mm Hg, pulse rate is 70/min, and respiration rate is 12/min. BMI is 26. The remainder of the examination is unremarkable.

Laboratory studies are significant for a serum LDL cholesterol level of 135 mg/dL (3.50 mmol/L) and serum HDL cholesterol level of 37 mg/dL (0.96 mmol/L). Urinalysis is negative for albuminuria.

Her estimated 10-year cardiovascular risk by the Pooled Cohort Equations is 2.7%.

Which of the following is the most appropriate cardiovascular disease risk management?

A. Aspirin
B. Coronary artery calcium scoring
C. Exercise stress testing
D. Folic acid supplementation
E. No further testing or therapy

MKSAP Answer and Critique

The correct answer is E. No further testing or therapy.

No further testing or therapy would be most appropriate in this patient. Although she has diabetes mellitus, she has no other major cardiovascular risk factors. Risk assessment for atherosclerotic cardiovascular disease (ASCVD) has traditionally been with the Framingham risk score, although the American College of Cardiology/American Heart Association Pooled Cohort Equations, a new method for assessment that includes additional variables for risk stratification, is increasingly being used. With this method, a 10-year risk of ASCVD of less than 5% is considered low risk, 5% to below 7.5% is considered intermediate risk, and 7.5% and above is designated as high risk. This patient has a calculated 10-year risk of 2.7%, making her low risk for ASCVD. Therefore, no additional testing is indicated at present.

It is reasonable to give low-dose aspirin to adults with diabetes and no previous history of vascular disease who are at increased cardiovascular risk and without increased risk for bleeding. However, aspirin should not routinely be given to patients with diabetes who are at low risk (men younger than 50 years and women younger than 60 years without other major risk factors such as hypertension or tobacco use). The risks of gastrointestinal bleeding or hemorrhagic stroke outweigh the benefits of aspirin in this low-risk patient.

Coronary artery calcium scoring is reasonable to further define cardiovascular risk in patients with intermediate risk as determined by the Pooled Cohort Equations (5% to <7.5%). However, this patient’s risk of ASCVD is considered low; therefore, good adherence to lifestyle factors and monitoring of cardiovascular risk factors are most appropriate in this patient.

There is no role for routine exercise testing in an asymptomatic patient. In patients with low coronary artery disease pretest probability, false-positive results will be more common than true-positive results and may lead to unnecessary downstream testing and treatment.

Although elevated homocysteine levels are associated with cardiovascular risk, no data support the use of folic acid supplementation, which can lower homocysteine levels, to reduce the risk.

Key Point

• Aspirin should not routinely be given to patients with diabetes mellitus who are at low cardiovascular risk (men younger than 50 years and women younger than 60 years without other major risk factors such as hypertension or tobacco use).

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