MOC Questions

Preparing for the American Board of Internal Medicine Maintenance of Certification

With the next Cardiovascular Disease Exam scheduled for May 10, 2006 (Interventional Cardiology is slated for November 9, 2006) and self-evaluation ongoing, it’s never too early to begin preparing. The following cases and questions should assist in fostering the continuing scholarship required for professional excellence in the practice of medicine. This section will be appearing every other month; we hope you find it useful.

Questions

1. Which one of these cardiac catheterization findings is the clearest indication for coronary revascularization?a single-vessel disease with abnormal left ventricular (LV) function

b significant narrowing of left main coronary artery

c 2-vessel disease with normal LV function

d asymptomatic 3-vessel disease

e angina pectoris controlled with medication

2. A 45-year-old woman with hypertension comes to the office for a routine examination. Before now, she would consider only lifestyle modifications to treat her hypertension. On this visit, her blood pressure is again elevated at 144/94 mm Hg, and she agrees to medication. You elect to start monotherapy with an angiotensin-converting-enzyme inhibitor. According to the Seventh Report of the Joint National Com­mittee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, 2 or more antihypertensive medications should be initiated when the blood pressure is over goal by _____ mm Hg systolic and _____ mm Hg diastolic.a 40; 20

b 30; 15

c 20; 10

d 15; 10

e 10; 5

3. The guidelines of the Seventh Joint National Com­mit­tee on Prevention, Detection, Evaluation, and Treat­ment of High Blood Pressure categorize consistent systolic blood pressure readings of 120-139 mm Hg in patients who do not have diabetes mellitus as _______.a high-normal blood pressure

b stage 1 hypertension

c borderline hypertension

d prehypertension

e mild hypertension

4. You have been caring for a 25-year-old woman for several months, and you now suspect that she has infective endocarditis. Which one of the following statements about this condition is false?a Compared with subacute endocarditis, acute endocarditis is more likely to spread hema­tog­­eneously.

b Appropriate prophylaxis for a patient with a prosthetic heart valve who is to have a dental procedure is amoxicillin (Amoxil, Trimox), 2 g by mouth 1 hour before the procedure.

c In injection drug users, the most common causative organism of infective endocarditisis Staphylococcus epidermidis.

d After valve replacement, the greatest risk for developing infective endocarditis is withinthe first 6 months.

e Patients who have infective endocarditis involving the tricuspid valve often present with pulmonary findings such as cough and pleuritic chest pain.

5. Which of these statements about measuring C-reactive protein (CRP) with a high-sensitivity assay (hsCRP) to determine the risk for coronary artery disease (CAD) is true?a Markedly elevated CRP values are highly correlated with significant CAD.

b The hsCRP assay is needed only when individuals who are at lower risk for CAD are being screened.

c Patients who have 2 or more CAD risk factors are considered most likely to benefit from CRP screening.

d CRP levels are consistently higher in patients with CAD than in those patients with acute infection.

e CRP levels may help identify patients at high risk for CAD despite a completely normal lipid profile.

6. Unless contraindicated, all of the following medications except ___________ are recommended for patients having unstable angina / non-ST-segment elevation myocardial infarction when they are discharged from the hospital.a aspirin and clopidogrel

b a beta blocker

c a statin

d an angiotensin-converting enzyme inhibitor

e a diuretic

7. In a patient who has nonvalvular atrial fibrillation, which of the following are considered risk factors for stroke?a age older than 75

b recent congestive heart failure

c hypertension

d diabetes

e a, b, and c

f a, b, c, and d

8. ________________ is the most important treatment objective for heart failure caused by diastolic dysfunction.a Control of hypertension

b Adequate diuresis

c Weight loss

d Maintaining low-density lipoprotein cholesterol below 100 mg/dL

e Increasing contractility with positive inotropic agents such as digoxin

9. A 67-year-old African-American man is brought to your urgent care clinic by his wife. He has left calf swelling. Eight weeks ago, he had open prostatectomy for prostate cancer without any complications. His left calf measures 4 cm more than the right calf but with no popliteal tenderness or pitting edema. The affected leg also has notable erythema and warmth. Which of the following interventions is now indicated?a chest radiograph and electrocardiogram

b a D-dimer assay

c computed tomography scan angiography with cuts extending through the thigh

d bilateral lower extremity duplex ultrasound

e empiric anticoagulant therapy

10. In patients with diabetes with nephropathy, which class of antihypertensive agents should not be used as initial monotherapy?a angiotensin-converting enzyme inhibitors

b diuretics

c b-blockers

d angiotensin receptor blockers

e dihydropyridine calcium channel blockers

Answers

1: bIn general, the prognosis for coronary artery disease (CAD) can be improved in 3 groups of patients: 1) those with left main artery disease, for whom virtually all studies in the literature show increased survival with revascularization; 2) those with 3-vessel disease and left ventricular (LV) dysfunction; and 3) those with significant CAD and evidence of silent ischemia. In addition, patients with CAD and angina refractory to medical management have an ex­cellent chance of improvement in controlling chest pain after revascularization procedures. Revasc­ularization generally does not improve survival in patients who have non-left main CAD, are asymptomatic, and have normal LV function.

Morrow DA, Gersh BJ, Braunwald E. Chronic coronary artery disease. In: Zipes DP, Libby P, Bonow RO, eds. Braunwald’s Heart Disease: A Textbook of Cardio­vascular Medicine. 7th ed. Philadelphia, Pa: Elsevier Saunders; 2005:1281-1354.

2: cMost hypertensive patients will re­quire 2 or more medications to reach blood pressure goals. When initial blood pressure is more than 20 mm Hg systolic and 10 mm Hg diastolic above goal, clinicians should consider initiating therapy with 2 agents, usually including a diuretic.

Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Ev­aluation, and Treatment of High Blood Pressure: The JNC 7 report. JAMA. 2003;289:2560-2572.

3: dPerhaps the most controversial concept of the Seventh Joint Na­tional Committee on Pre­vention, Detection, Evaluation, and Treat­ment of High Blood Pressure (JNC-7) was introduction of the new term, prehypertension, for classifying individuals who manifest consistent blood pressure readings between 120-139/80-89 mm Hg. With 1 stroke of the pen, 45 million Ameri­cans be­came grouped in this new classification. Prehyper­tension is not a disease. It does, however, identify an at-risk group, for whom determined lifestyle modification ef­forts may provide great benefit. Previous terms for persons with blood pressure readings that fall within this range included high-normal blood pressure, mild hy­pertension, and borderline hy­pe­rtension. None of these previously used terms, however, successfully motivated patients to work diligently on lifestyle factors. If hypertension was only “mild” or “high normal,” why bother to lose weight and exercise? The hope of the JNC-7 panel was that use of the term prehypertension would be heeded and serve as a wake-up call to facilitate our efforts as health care providers toward motivating our patients to incorporate beneficial lifestyle changes into their everyday existence, and therefore ward off progression to definite (that is, stage 1) hypertension.

Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC-7 Report. JAMA. 2003;289:2560-2572.

4: cStaphylococcus aureus, not Sta­phy­lococcus epidermidis, is the most common cause of endocarditis in injection drug abusers. This is important because many strains are methicillin resistant. Acute endocarditis is a more vigorous entity than subacute endocarditis and has a more rapid progression. Unt­reated, it can lead to death in weeks. Subacute endocarditis evolves slowly and rarely seeds hematogeneously to other structures. Amoxicillin, 2 g by mouth 1 hour before a dental procedure, is advised in those at high or moderate risk for endocarditis. While the benefit of prophylaxis has not been fully established, it is still recommended. The risk for endocarditis after prosthetic valve replacement is greatest within the first 6 months. If it develops within the first 2 months, bacterial contamination during the procedure or bacteremia after the procedure are the most likely causes.

In injection drug users who develop endocarditis, about half have disease only in the tricuspid valve; most of these tricuspid cases present with pulmonary findings such as cough, pleuritic chest pain, infiltrate, and pyopneumothorax.

Karchmer AW. Infective endocarditis. In: Fauci AS, Braunwald E, Hauser SL, eds. Harrison’s Principles of Internal Medicine. 15th ed. New York, NY: McGraw-Hill;2001:809-816.

5: eIncreased levels of C-reactive protein (CRP) are now recognized as a strong predictor of coronary artery disease (CAD). An important feature of the CRP assay is its ability to identify a group of individuals who, despite normal levels of low-density lip­o­protein cholesterol (LDL-C) and few conventional risk factors, are nevertheless at significant risk for CAD.

Because CRP is a generalized marker of inflammation, interpretation of the test can be problematic in patients with systemic pro­cesses such as acute infection, rheumatoid arthritis, or cancer. For this reason, markedly elevated CRP values are usually considered spurious and indicative of some systemic process other than CAD. In contrast, slight but consistent elevations in CRP levels that are not associated with other inflammatory conditions serve as important predictors of risk for CAD. These patients may benefit from primary prevention with HMG-CoA reductase inhibitors (stat­ins), even though their LDL-C levels may be normal; they can also be targeted for more intense efforts at lifestyle modification.

Ridker PM, Hennekens CH, Buring JE, et al. C-reactive protein and other markers of inflammation in the prediction of cardiovascular disease in women. N Engl J Med. 2000;342(12):836-843.

6: eFive medications have a New York Heart Association class I recommendation for long-term treatment of patients after unstable angina / non-ST-segment elevation myocardial infarction. A diuretic does not have this recommendation. Statins should be continued as a secondary prevention. Aspirin should be given, and if it is not tolerated, clopidogrel can be used. Clopidogrel can also be given with aspirin for up to 9 months. Beta blockers should be continued to control symptoms. Angiotensin-converting enzyme inhibitors have shown favorable effects with long-term use in patients with coronary artery disease.

Wiviott S, Braunwald E. Unstable angina and non-ST-segment elevation myocardial infarction: Part II. Coronary revascularization, hospital discharge, and posthospital care. Am Family Physician. 2004;70:535-538.

7: fNot all consensus statements concerning patients with nonvalvular atrial fibrillation consider diabetes a risk factor for stroke, but most of them do. There is general agreement that the presence of 2 or more of the risk factors listed—age older than 75, recent congestive heart failure, hypertension, and diabetes—warrant using warfarin as treatment in this situation to prevent stroke. If just none or one is present, the annual risk is thought to be 1% or less, and warfarin is not indicated.

Guthman RA. Which patients with atrial fibrillation do not need anticoagulation therapy with warfarin? Am Fam Physician. 2004;70:917-918.

8: aGeneral consensus on the optimal management of patients with heart failure from diastolic dysfunction is lacking because randomized, pro­spective, controlled clinical trials on the treatment of this disorder do not exist. The one area of agreement on therapeutic approaches is the need for vigorous blood pressure control.

Hyper­tension is by far the most important predisposing factor to development of diastolic dysfunction heart failure, since it leads to concentric hypertrophy with consequently im­paired ventricular compliance and reduced left ventricular filling. The hope is that normalization of blood pressure may reverse some of the abnormalities seen with diastolic dysfunction.

Excessive diuresis may be deleterious in patients with pure diastolic dysfunction (if it leads to volume depletion with further reduction in cardiac output). Increasing contractility with positive inotropic agents is also not indicated. Weight loss and treatment of hyperlipidemia are beneficial lifestyle changes, but not specific for treatment of heart failure with diastolic dysfunction.

Lee TH. Guidelines: Management of heart failure. In: Zipes DP, Libby P, Bonow RO, et al, eds. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 7th ed. Philadelphia, Pa: WB Saunders; 2004:617-624.

9: bWells criteria for deep venous thrombosis (DVT) assign 1 point for each of the following risk factors: cancer within 6 months, immobilization, bedridden because of surgery in the previous 4 weeks; deep vein distribution tenderness; swelling in the entire leg; unilateral calf swelling of more than 3 cm below the tibeal tuberosity; unilateral pitting edema; and collateral superficial veins. The important thing to remember when using these criteria is to subtract 2 points for an alternative diagnosis that is just as likely or more likely than DVT. This patient has a risk of 2 (cancer and calf swelling), but he also shows evidence of cellulitis (-2), since DVT does not usually cause erythema and warmth, giving him a risk score of zero. Risk scores are interpreted as follows: 0 = low, 1-2 = moderate, and more than 3 = high. Those with moderate and high risk go directly to ultrasound regardless of D-dimer results; low risk may be excluded by a negative D-dimer result.

Wells PS, Anderson DR, Bormanis J, et al. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet. 1997; 350:1795-1798.

10: eAngiotensin-converting enzyme (ACE) inhibitors can delay the progression from microalbuminuria to macroalbuminuria and slow decline in glo­merular filtration rate in patients with macroalbuminuria. Angiotensin re­ceptor blockers (ARBs) have also been shown to reduce the rate of progression from microalbuminuria to macroalbuminuria, as well as end-stage renal disease in type 2 diabetes. Dihydropyri­dine calcium channel blockers as initial therapy are no more effective than placebo in slowing the progression of nephropathy. Their use should be restricted to added therapy to further lower blood pressure in patients treated with an ACE inhibitor or ARB.

Ameircan Diabetes Association. Standards of medical care in diabetes. Diabetes Care. 2004;27(suppl 1):S15-S35.