Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.
A 62-year-old woman is evaluated during a routine examination. She feels well and has no exercise limitations. Medical history is significant for hypertension treated with enalapril. She does not smoke. At her last examination 4 years ago, her blood pressure was 122/76 mm Hg. Laboratory studies at that time revealed a serum total cholesterol level of 184 mg/dL (4.77 mmol/L), serum HDL cholesterol level of 42 mg/dL (1.09 mmol/L), and HbA1c value of 5.4%. At that time, according to the Pooled Cohort Equations, her 10-year risk for atherosclerotic cardiovascular disease was calculated to be 3.8%. She has gained 5 kg (11 lb) since then.
On physical examination today, blood pressure is 140/90 mm Hg. BMI is 29. The remainder of the physical examination is unremarkable.
Laboratory studies are significant for a serum total cholesterol level of 250 mg/dL (6.47 mmol/L), a serum HDL cholesterol level of 30 mg/dL (0.78 mmol/L), and an HbA1c value of 6.6%. A subsequent fasting plasma glucose level is 130 mg/dL (7.2 mmol/L).
Which of the following confers the highest risk for atherosclerotic cardiovascular disease in this patient?
A. Diabetes mellitus
B. Diastolic blood pressure of 90 mm Hg
C. HDL cholesterol level of 30 mg/dL (0.78 mmol/L)
D. Systolic blood pressure of 140 mm Hg
E. Total cholesterol level of 250 mg/dL (6.47 mmol/L)
MKSAP Answer and Critique
The correct answer is A. Diabetes mellitus.
The factor associated with the highest risk for atherosclerotic cardiovascular disease (ASCVD) is the diagnosis of diabetes mellitus. The presence of diabetes is associated with increased cardiovascular risk, particularly among women. Patients with diabetes have a two to four times increased risk for cardiovascular disease, with more than two thirds of patients with diabetes eventually dying of heart disease. The risk for stroke is increased 1.8- to 6-fold in patients with diabetes. Additionally, patients with diabetes are more likely to have undiagnosed coronary artery disease and have worse outcomes when hospitalized for other cardiovascular diseases, such as heart failure. In this patient, the development of diabetes alone (with all other risk factors held constant) nearly doubled her 10-year risk for ASCVD. Her current 10-year risk, including diabetes, changes in her age, and blood pressure and lipid levels, is 19.4%. Appropriate treatment of cardiovascular risk factors in patients with diabetes is associated with reduced cardiovascular risk. The most recent American College of Cardiology/American Heart Association cholesterol treatment guideline recommends that patients aged 40 to 75 years with diabetes and a 10-year ASCVD risk greater than or equal to 7.5% should receive high-intensity statin therapy. In patients in this age group with diabetes and a 10-year risk less than 7.5%, moderate-intensity statin therapy is recommended.
A diastolic blood pressure of 90 mm Hg, HDL cholesterol level of 30 mg/dL (0.78 mmol/L), systolic blood pressure of 140 mm Hg, and total cholesterol level of 250 mg/dL (6.47 mmol/L) have a relatively small effect on 10-year ASCVD risk compared with the presence of diabetes.
Key Point
- Patients with diabetes mellitus have a two to four times increased risk for cardiovascular disease, with more than two thirds of patients with diabetes eventually dying of heart disease.
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